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Evidence-Based Diabetes Management September 2018

In the Era of Payment Reform, Diabetes Educators Can Lead the Way Toward Value-Based Care

Robert Gabbay, MD, PhD, FACP
This article is based on a keynote presentation at the 2018 annual conference of the American Association of Diabetes Educators.
For a healthcare system that spends more per person than any in the world,1 Americans are in not in superior health compared with other developed countries.2 This does not make sense, but much of what occurs in the US health system has not made sense—until one considers how our system of reimbursement has functioned for decades.

Our system of fee-for-service reimbursement—of being paid to do things—has created incentives that reward process, not outcomes. This has meant that care for diabetes, while an essential component of any health system, has been looked upon as a “cost center.” Meanwhile, the parts of our system that deal with the complications of diabetes, like a cardiac wing for heart surgery, have been seen as “revenue centers.”

Fortunately, and especially so for diabetes educators and other diabetes professionals, the system is changing. We’re moving from a fee-for-service world to one where value is key, with value being defined as improving health outcomes while reducing costs, or least getting better outcomes for the same cost. That is shift is happening now, and it will fundamentally change the work of diabetes educators.

Diabetes Educators: the Value People

The Medicare Access and CHIP Reauthorization Act (MACRA), is the biggest change in the way providers are paid in more than 25 years.3 MACRA fundamentally changes the compensation structure for providers, and it sets in motion the transition from fee-for-service to a fee-for-value system with the Merit-based Incentive Payment System, or MIPS. This starts with a fee-for-service payment, but adds a significant value component or score based on 4 elements: (1) quality, (2) resource utilization, or cost; (3) engagement in practice improvement, and (4) use of electronic health records. Of these elements, quality is the most heavily weighted.

While a MIPS score could initially cause payments to vary by 3% to 4%, eventually a MIPS score could swing payments by 9% to 10%. Thus, although some qualified providers are still learning about MIPS, at some point these shifts will capture everyone’s attention, and the focus on quality will be essential. In fact, 2017 data in many cases has been used to adjust 2019 payments.3

How will quality be measured? Many of the measures that determine quality are measures used in diabetes care, such as the percentage of patients who achieve a glycated hemoglobin (A1C) below 9%. Proivders could complete MIPS reporting requirements on diabetes measures alone.

If we are moving to a system that rewards value, there are incentives to offer better diabetes care. And that makes the role of diabetes educators so important: The good news is, the services educators provide are relatively inexpensive—although, sadly, this is due to the fact that educators are paid less than they should be paid.4

From a health system perspective, however, diabetes educators are the value people: they teach patients self-management and provide support; they offer both specific information and encouragement in areas that include nutrition, exercise, and stress reduction; and they can identify those patients most at risk of complications or hospitalization and work with them to improve glycemic control.

By fully deploying diabetes specialists—in both traditional and new roles—health systems have the opportunity under new payment models to convert traditional cost centers involving diabetes care into potential savings centers.

ACOs and the Value Shift

Improved diabetes care is the foundation of savings seen in accountable care organizations (ACOs), which saved Medicare nearly $1 billion over their first 3 years, according to a 2017 report of the HHS Inspector General.5 ACOs receive a lump sum to care for a population; if they succeed in improving quality and reducing costs, they are able to keep some of the money Medicare saves. ACOs have improved quality by reducing readmissions, by scheduling primary care hours later in the day to accommodate work schedules, and by thinking not only about the patients who come through the door, but those who haven’t shown up. Population health strategies demand that health systems engage with the community to identify those at high risk of costly events or complications, and take preventive steps, such as more screenings or adding office hours for primary care that more easily accommodate working people.

As it has in the past, diabetes care will lead the way.

Elliott Joslin, the founder of Joslin Diabetes Center, became the world’s first diabetologist and the earliest diabetes epidemiologist by keeping registries of all his patients, in which he recorded their natural history and potential complications. He trained the “wandering nurses,” who today are called diabetes educators, to teach patients about the importance of exercise, attention to diet, and, later, proper insulin dosing.6 From this early example of population management, we see the origins of today’s patient-centered medical home (PCMH) and the team-based approach that has been shown to improve outcomes for people with diabetes. We also see the idea of the “medical neighborhood,” which is essential to a well-functioning ACO. This includes not only the PCMH, but also medical and non-medical partners, including hospitals, home health care, specialists (such as a ophthalmologists), and mental health professionals, as well as community resources like school systems, large employers, or food pantries.7

What makes diabetes care the foundation of the reimbursement shift we are seeing? The disease meets each of the “5 Cs”:
  • It is Costly: medical costs and lost productivity now account for $327 billion per year in the United States.8
  • It is Common: according to CDC, 9.4% of Americans has the disease.9
  • It is Complex: diabetes can be managed with a choice of over 12 classes of drugs along with lifestyle changes.
  • It is Calculable: progress in diabetes management can be measured in A1C, blood pressure, and cholesterol levels, in weight loss, by how often a patient experiences hypoglycemia and by time in range.
  • It has Complications that are preventable: a goal of good diabetes care is to avoid long-term outcomes such as retinopathy, renal disease, or lower limb amputations, which are responsible for most of the costs of diabetes.
Changing Reimbursement, Changing Opportunities

Under the shift to value-based care, health systems will be wise to add professionals who can help (1) identify those members of the population who are high-risk and likely to incur high costs, and (2) to intervene with those patients to take preventive steps to avoid major events or disease progression. There are 3 distinct opportunities where diabetes educators can be valuable to health systems as they shift their focus to population health management: 
  1. Practice coaching. Primary care practices often struggle to make the leap to a PCMH, since they must do so while meeting their patients’ day-to-day needs. Diabetes educators can help practices make the shift, because they are already experts in negotiated goal setting, problem solving, empowering, team dynamics, and cheerleading.
  2. Care management. If the goal is to reduce costs and improve quality, diabetes educators are well-positioned to be experts in risk stratification and working with high-risk patients, both those who are newly diagnosed with type 2 diabetes (T2D) and those who have lived with the disease for some time. Data from the Agency for Health Research and Quality show that 10% of high-risk patients account for two-thirds of the costs—the key is finding that 10%.10
  3. Augmenting digital care. For all the excitement about using digital therapeutics to manage diabetes, researchers are finding that early engagement tends to wane over time. A key seems to be finding a way to combine the technology with the human touch to ensure ongoing use. Competition in the diabetes digital technology sector ensures that companies will seek those with expertise in diabetes care and patient engagement.
In many ways, there has never been a time of greater opportunity for diabetes educators. It is important for those who understand how to identify those patients most in need of care—and how to motivate them to stick with a self-management plan—to step forward, both within their health systems and beyond. We can, and should, expect to see greater numbers of diabetes educators engaged in new roles as the transition to payment for value takes hold. 




 
Dr Gabbay is the chief medical officer and senior vice president of Joslin Diabetes Center. He is editor-in-chief of Evidence-Based Diabetes Management.
References
  1. Sawyer B, Cox C. How does health spending in the US compare to other countries? Peterson-Kaiser Health System Tracker. healthsystemtracker. org/chart-collection/health-spending-u-s-compare-countries/#item-relative-size-wealth-u-s-spends-disproportionate-amount-health. Published February 13, 2018. Accessed August 30, 2018.
  2. Papanicolas I, Woskie LR, Jha AK. Health care spending in the United States and other high-income countries. JAMA. 2018;319(10):1024-1039. doi: 10.1001/jama.2018.1150.
  3. CMS. What’s MACRA? CMS website. cms.gov/Medicare/Quality-Ini- tiatives-Patient-Assessment-Instruments/Value-Based-Programs/ MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html. Updated May 30, 2018. Accessed August 30, 2018.
  4. White MC. These jobs will bring you satisfaction no matter how much you earn. Money online. time.com/money/4487966/these-jobs-will-bring-you-satisfaction-no-matter-how-much-you-earn/. Published September 13, 2016. Accessed August 30, 2018.
  5. Office of the Inspector General. Medicare Shared Savings Program. Accountable care organizations have shown potential for reducing spending and improving quality. HHS website. oig.hhs.gov/oei/ reports/oei-02-15-00450.asp. Published August 28, 2017. Accessed August 30, 2018.
  6. Elliott P. Joslin. Joslin Diabetes Center website. joslin.org/about/ elliot_p_joslin_md.html. Accessed August 30, 2018.
  7. Medical neighborhood. Patient-Centered Primary Care Collaborative website. pcpcc.org/content/medical-neighborhood. Accessed August 30, 2018.
  8. American Diabetes Association. Economic costs of diabetes in the US in 2017. Diabetes Care. 2018;41(5):917-928. doi.org/10.2337/dci18-0007.
  9. New CDC report: more than 100 million Americans have diabetes or prediabetes [press release]. Atlanta, GA: CDC website; July 18, 2017. cdc.gov/media/releases/2017/p0718-diabetes-report.html. Accessed August 30, 2018.
  10. Cohen SB, Yu W. The concentration and persistence in the level of health expenditures over time: estimates for the US population, 2008-2009. Statistical Brief #354, Agency for Healthcare Research and Quality. meps.ahrq.gov/data_files/publications/st354/stat354.shtml. Published January 2012. Accessed August 30, 2018.
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