Diabetes Optimal Care Not Cost Effective

Reimbursement is only part of the problem…. 

The prevalence of diabetes in the United States has gone up astronomically in the last 30 years, and is projected to do so well into the future. With about 5.6 million people in 1980 to about 19.7 people in 2009 living with diabetes, it has almost tripled in that timespan with a projected prevalence of over 42 million by the year 2034. With the increasing rate of diabetes also comes a high cost of treating diabetes mainly due to the complications of diabetes. Previous studies have shown that diabetes complications can be reduced in cost-effective ways, but these ways haven’t been very successful because of several barriers to providing care. The main barrier to providing care is costs: the costs it takes to provide optimal diabetes care does not reflect the reimbursement clinicians receive for providing such care. As a result, care is often limited and incomplete. This study was performed to determine the obstacles to providing care and potential solutions to overcoming these obstacles.

An internet-based survey was created by The Diabetes Working Group, a collection of professional organizations and individuals, to determine the demographics and practice patterns of diabetes care providers. The survey was sent to members of five organizations: the American Diabetes Organization, the Endocrine and Pediatric Endocrine Society, the American Association of Clinical Endocrinologists, and the American Academy of Pediatrics. A total of 1,267 responses to the survey were collected. Expert panels developed a 28-point standard of care for optimal diabetes care and clinical vignettes of 6 different diabetic patients that represented a broad spectrum of diabetes patients, and then estimated the amount of time and money needed to achieve the standard of care for each patient type. The cost it took to provide care for these patients and reimbursement amounts was calculated using the average number of patients seen per week (as provided in the survey) multiplied by the average number of patients seen in a year based on national estimates. The results were unanimous in showing that provided costs exceeded reimbursements for all patient scenarios. The cost of treating adult patients would exceed reimbursement by over $750,000/year and pediatric patients by $471,000/year. Providers would require a 19% increase in overall reimbursement just to break even.

In order for optimal diabetes care to be successful, changes should be made in care management, payment reform, and workforce supply. The following suggestions may help overcome such financial obstacles:

• Increasing the use of shared decision making would increase a patient’s motivation to reach treatment goals that are their own instead of goals created by a provider. Participating in patient registries and/or databases would be useful to track goal achievement. The use of electronic prescriptions would help improve monitoring of medication adherence.
• Billing codes should be revised to ensure that adequate payment is achieved. Also, a monthly per-patient payment for all care would be useful into accounting for the multidisciplinary team required to provide the optimal standard of care. Financial incentives should be put in place to allow more time with diabetic patients. Forgiving educational loans might be effective in making diabetes care a more appealing choice for prospective health care professionals and can counteract the reputation of diabetes care as an underpaid profession.

In conclusion, optimal diabetes care is currently impractical given the inequality between provider costs and provided reimbursements, and several changes are suggested to help relieve this problem.

Diabetes/Metabolism Research & Reviews 2014: Vigersky, R. et al. "Barriers and Potential Solutions to Providing Optimal Guideline-Driven Care to Patients With Diabetes in the U.S." Diabetes Care. 2013;36(11): 3843-3849