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Evidence-Based Diabetes Management December 2016
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Making Early, Consistent Diabetes Self-Management Education and Support the Norm, Not the Exception
Robert A. Gabbay, MD, PhD, FACP; and Hope Warshaw, MMSc, RD, CDE, BC-ADM, FAADE
Existing DSME Network Could Create Foundation to Scale National Diabetes Prevention Program Across 50 States
Mary K. Caffrey
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Making Early, Consistent Diabetes Self-Management Education and Support the Norm, Not the Exception

Robert A. Gabbay, MD, PhD, FACP; and Hope Warshaw, MMSc, RD, CDE, BC-ADM, FAADE
The 2015 joint statement of the American Association of Diabetes Educators, the American Diabetes Association, and the Academy of Nutrition and Dietetics called for diabetes self-management education and support at 4 distinct points: at diagnosis, at annual assessments, when complications arise, and at transitions.
Each year, about 1.7 million adults in the United States learn they have diabetes, with the vast majority receiving a diagnosis of type 2 diabetes (T2D).1 What if each person, upon learning he or she had T2D, received a cost-effective treatment—one proven to keep people out of the hospital, increase medication adherence, and lessen the likelihood of retinopathy or kidney disease?

The good news is that “treatment” is already available as a service covered by most health plans and Medicare, yet underutilized by providers and patients. It’s called diabetes self-management education and support, or DSMES, and there’s solid evidence it works and saves the healthcare system money.2 The bad news? The number of people with T2D who receive DSMES in the first year after diagnosis is “disappointingly small,” according to a 2015 joint position statement from the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics.3  

Recent research shows only 6.8% of those with T2D in private plans get DSME in the first 12 months after diagnosis,4 and only 4% in Medicare do.5 Meanwhile, the annual cost of diabetes care in the United States was $245 billion in 2012, including $1 of every $3 spent in Medicare.6  

Engaging people with T2D in their diabetes self-care behaviors to learn the essentials about diabetes and preventing the progression of disease are 2 key goals of DSMES. The joint position statement, titled “Diabetes Self-Management Education and Support in Type 2 Diabetes,” identifies the 4 time points when DSMES should be provided or considered: (1) at diagnosis, (2) at annual assessments, (3) when a new complications occur, and (4) during transitions in life and care.3  

As the joint position statement points out, learning about a T2D diagnosis can be overwhelming, and the emotional response can range from depression to denial. People must figure out how to fit the elements of daily self-care of diabetes into their life. DSMES can help them achieve this goal. Since so much care for T2D is offered by primary care providers (PCPs), the statement says that PCPs should make these referrals early and should also encourage people to involve spouses or other essential care givers or supporters.  

Providing DSMES early on serves many purposes: it drives home the message that a T2D diagnosis must be taken seriously, it identifies those people who need more psychosocial support, and it encourages good self-care management habits early in the life cycle of the disease. Complications are not inevitable. It’s critical that people with diabetes understand this from the beginning.

What can be done to improve referral to and participation in the currently underutilized DSMES? First, providers, and PCPs, in particular, must understand that the value of DSMES cannot be achieved if it’s offered only once; as the disease progresses, self-management education must progress with it. Streamlining the referral process and eventually allowing patients to self-refer once they are diagnosed with diabetes could facilitate access. Even a person actively engaged in their disease management will have different questions after a decade of living with T2D than he or she had when first diagnosed. Medications and management tools change, and complications create moments of critical need.  

The role for payers in facilitating DSMES enrollment cannot be overstated. Since Medicare initiated reimbursement of DSMES about 15 years ago provided by accredited programs, CMS only covers 10 hours of initial education in the first year of diagnosis and 2 hours a year after that. These limits, which may change in the near future,7 have been adopted by many private payers but barely cover the needs of many people with diabetes. And while the limited CMS hours of service may be adequate for some patients, the “once and done” approach is at odds with our current understanding of the progressive nature of diabetes.  A 2016 review article in Patient Education and Counseling found that there is evidence that offering more than 10 contact hours results in statistically significant reductions in A1C, and that more research is needed in this area.8 If anything, a July 2015 report from Harvard Law School found that payers should find ways to increase access to DSMES, such as getting rid of cost sharing. The Harvard study found that given the cost of diabetes to healthcare systems and society, reducing or ending cost sharing will result in cost savings in most cases.2  

Besides cost, lack of convenience is a known barrier to participation. The joint position statement suggests that integrating DSMES into the primary practice or using digital formats can greatly improve and increase access, as well as the quality of communication with diabetes educators.  

The quest now is to move referral and utilization of DSMES from a recommendation to an expectation. Today, people who fail to follow through on a referral for a mammogram, a colonoscopy, or blood work know they will hear about it at the next visit. In diabetes care, DSMES must be treated with the same urgency. It’s in the interest of accountable care organizations, which already promote DSMES, to build awareness, remove barriers, and make this essential element of diabetes care a priority. If the connection between diabetes measures and payment is here to stay, it only makes sense to enlist people with the disease in managing it. 
Robert A. Gabbay, MD, PhD, FACP, is the senior vice president and chief medical officer of Joslin Diabetes Center and editor in chief of Evidence-Based Diabetes Management™. Hope Warshaw, MMSc, RD, CDE, BC-ADM, FAADE, is an author, consultant, and diabetes educator. She is the 2016 president of the American Association of Diabetes Educators. 
References

  1. Centers for Disease Control and Prevention. Diabetes latest. CDC website. http://www.cdc.gov/features/diabetesfactsheet/. Updated June 17, 2014. Accessed September 15, 2016.

  2. Garfield K, Downer S, Rosenberg A. Reconsidering cost-sharing for diabetes self-management education: recommendations for policy reform. Center for Health Law and Policy Innovation website. http://www.chlpi.org/new-publication-reconsidering-cost-sharing-for-diabetes-self-management-education-recommendations-for-policy-reform/. Published July 9, 2015. September 28, 2016.

  3. Powers MA, Bardsley J, Cypress M, et al. Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Care. 2015;38(7):1372-1382. doi: 10.2337/dc15-0730.

  4. Li R, Shrestha SS, Lipman R, Burrows NR, Kolb LE, Rutledge S; Centers for Disease Control and Prevention (CDC). Diabetes self-management education and training among privately insured persons with newly diagnosed diabetes—United States, 2011-2012. MMWR Morb Mortal Wkly Rep. 2014;63(46):1045-1049.

  5. Duncan I, Birkmeyer C, Coughlin S, Li QE, Sherr D, Boren S. Assessing the value of diabetes education. Diabetes Educ. 2009;35(5):752-760. doi: 10.1177/0145721709343609.

  6. American Diabetes Association. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2013;36(4):1033-1046. doi: 10.2337/dc12-2625.

  7. American Association for Diabetes Educators. Comments to proposed 2017 Medicare Physicians’ Fee Schedule. American Association for Diabetes Educators website.
https://www.diabeteseducator.org/docs/default-source/practice/pfsresponse_aade_dsmt_mdpp.pdf?sfvrsn=20. Submitted September 1, 2016. Accessed September 29, 2016.

  8. Chrvala CA, Sherr D, Lipman RD. Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control. Patient Educ Couns. 2016; 99(6):926-943. doi: 10.1016/j. pec.2015.11.003.
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