Barriers and Solutions to Optimal Diabetes Care

The Diabetes Working Group (DWG) survey finds that provider costs exceeded reimbursement rates for all scenarios presented…. 

The DWG, a compilation of professional organizations and individuals was created to look at the current barriers for providing optimal care and to recommend solutions to these barriers. As the prevalence of diabetes grows in the US, the cost care and the need for someone to provide diabetes care will only continue to grow. Guidelines have been researched, developed, and proven to be successful yet there are still barriers to getting them into clinical practice. These barriers include the patients themselves whether that be behavioral, psychosocial, or socioeconomic that hinder patients from getting what they need. Other barriers include structural and technological hurdles and concerns of those providing care, like reimbursement.

An internet based survey included all the members of the various diabetes organizations. Using the standards-of-care economic model, an estimate was formed of the resources necessary for providers to consistently follow and deliver current diabetes standards of care. The costs to the provider for delivering such care were also estimated. Six clinical cases were developed to represent a broad spectrum of T1 and T2 diabetes patients. The minimum and maximum times needed to provide standard care was also measured. Times were linked to billing codes and reimbursement rates were determined. After crunching numbers, the results showed that provider costs exceeded reimbursement rates for all scenarios presented. What this ultimately reveals is that compensation for providing the best diabetes care is inadequate and inconsistent with national standards.

The DWG recommends making changes in three areas of providing diabetes care; care management, payment reform, and increasing workforce supply. Care management involves increasing engagements between providers and patients. By allowing patients to be involved and encouraging never-ending self-management a patient can become empowered to take charge of their own health. Creating a strong healthcare team including physicians, nurses, dieticians, clinical diabetes educators, and even pharmacists can increase the amount of care provided and access to it. Payment reform will require a number of things, like a broad spectrum of payment solutions to address all payment barriers. New codes need to be made to ensure that the appropriate work is being provided for an adequate payment. An episode-of-care payment model would allow for reimbursement of multiple services at one time covering different providers and types of care. The patient-management-fee model provides a monthly per-patient payment for all care. The diabetes-focus PCMH option encourages both care coordination and aligns reimbursement incentives while also incorporating guideline directed quality measures. In order to meet the demand of diabetes care, the number of people providing care needs to increase. Without incentives, health care providers are unlikely to join the diabetes care workforce. Solutions include providing loan forgiveness or financial assistance to those who choose to specialize in diabetes care, especially in underserved areas. The workforce can also be increased by providing financial incentives for more time spent with diabetic patients. Another approach is "force multipliers" that encourages better educating nurse practitioners and physician assistants. Without change, the current system of providing high quality care with little compensation just won’t work. These solutions provided by the DWG will help make providing optimal care more realistic.

• Enhanced provider/patient communication leads to greater adherence among patients with diabetes.
• Better aligning payment with desired patient outcomes can both improve outcomes and lower costs through decreasing emergency department and inpatient hospital use.
• Expanding the workforce is a necessary investment if we are to have a chance at resolving the barriers to optimal diabetes care

Vigersky, R. et al. Barriers and Potential Solutions to Providing Optimal Guideline-Driven Care to Patients With Diabetes in the US. Diabetes Care; 36(11):3843-3849. November 2013.