Diabetes Educators in Accountable Care Organizations: Meeting Quality Measures Through Diabetes Self-Management Education and Care Coordination
Mary Ann Hodorowicz, RDN, MBA, CDE, CEC
A Shift in Care in Primary Care
Since the advent of the Affordable Care Act (ACA), our healthcare system has continued to evolve in multiple ways, with more sweeping changes likely to come. Both entity and individual providers, especially in primary care, are seeing a shift away from care that is reactive, clinician centered, fragmented, and reimbursed on a fee-for-service (FFS) basis; care is becoming more proactive, patient centered, coordinated, and e-connected, with reimbursement based, in part, on meeting select quality measures.
The emphasis on primary care is due to many factors; most notably, these settings have a larger volume of patients with chronic disease; they use more care and expensive care. Hundreds of studies have demonstrated significant improvement in patient outcomes in primary care. Health insurers have responded with new risk-adjusted incentive payment models that increasingly require primary care providers to meet and report quality measures for patients with chronic diseases, including diabetes. This payment requirement has penetrated accountable care organizations (ACOs), as ACOs are largely comprised of primary care entities and individual providers. The 2-part bottom line is straightforward: when the quality of care increases through the achievement of quality measures, the overall cost of care decreases. Thus, when ACOs implement interventions proven to result in this bottom line, they are poised to receive incentive payments from health insurers. One such key intervention is diabetes self-management education (DSME) and support for persons with diabetes (PWD).
First: About Accountable Care Organizations
An ACO is a voluntary network of multiple healthcare providers with a single system of shared governance. An ACO can include hospitals, clinics, nursing homes, skilled nursing homes, home health agencies, internal medicine and family practice physicians, multispecialty physician practice groups, and other providers. It manages the full continuum of care with an emphasis on wellness and prevention, treating the whole patient, accountability for cost control, and on improving outcomes for assigned patient populations (eg, Medicare beneficiaries). Sophisticated electronic medical records, analytics, case management, team collaboration, and warm hands-on patient care coordination are essential tools to ensure patients receive the right evidence-based quality care at the right time in a cost-efficient manner as they transition from one provider to another. The ACO negotiates a range of payment models with health insurers (ie, capitation, bundled payments, and fee-for-service or FFS); however, the prominent models are bonus/incentive payments and shared cost savings stratified according to diseases/conditions, risk, and/or utilization history. The Medicare Shared Savings Program (MSSP) is an example of the latter payment method. The ACO strives to meet and report requisite quality measures on assigned beneficiary panels with certain diseases/conditions (including diabetes), in order to be reimbursed a portion of the Medicare savings it generates. The MSSP can also include various levels of financial risk, in which the ACO would have to pay back a specified portion, or all of the costs, that exceeded Medicare’s established benchmark. Many ACOs are participating in the MSSP, for reasons that include the unprecedented wave of Medicare beneficiaries expected in the next few years, as well as the possibility that the experience will set or revise benchmarks for commercial reimbursement models. The ACO is thus accountable to its patients and third-party payers for the quality, appropriateness and efficiency of the healthcare provided throughout its network.
This framework is what makes ACOs an ideal healthcare delivery model for the care of a person with diabetes (PWD). Diabetes is a chronic disease with substantial morbidity and mortality and, thus, enormous costs. These burdens are reduced by the provision of diabetes self-management education and support. DSME has been shown to be cost-effective by reducing hospital admissions and readmissions, as well as estimated lifetime healthcare costs related to a lower risk for complications.1-3 The findings indicate that the benefits associated with education on self-management and lifestyle modification are positive and outweigh the costs associated with this intervention. Per 2014 data from CDC, the indirect and direct total cost of diabetes in the United States in 2012 was reported to be $245 billion; DSME offers an opportunity to decrease these costs.4,5 To this end, healthcare professionals, as well as researchers inside and outside academia, agree that diabetes educators are key members of the ACO healthcare team. Their specialized skills are particularly well suited to aid the organization in 2 distinct and significant ways: 1. To help the ACO meet its payers’ requisite quality measures for sharing in cost savings under the MSSP and in obtaining value-based payments from commercial insurers. 2. To assume advanced roles and responsibilities such as members of the care coordinator team.
Diabetes is a Serious Public Health Concern
For a PWD, the risk of death is 2 times that of a person of similar age who does not have the disease.2 In 2012, 29.1 million Americans, or 9.3% of the population, had diabetes.3 Of these, the percentage who are 65 years and older remains high—25.9%, or 11.8 million seniors (diagnosed and undiagnosed).3 These data make the case for Medicare shared savings reimbursement to ACOs who care for beneficiaries with diabetes. Although these data are very discouraging, it does substantiate the need for PWDs to receive both initial and ongoing follow-up DSME in order to improve the entire spectrum of outcomes: learning, behavior, clinical, quality of life, cost-savings, and satisfaction (patient, provider, and payer).
Definition and Benefits of Diabetes Self-Management Education and Support
The National Standards of Diabetes Self-Management and Support define DSME as: “The process of facilitating the knowledge, skill, and ability necessary for diabetes self-care.” The standards define DSMES as: “Activities that assist the person with diabetes in implementing and sustaining the behaviors needed to manage his or her condition.”4
This intervention focuses on the AADE7 Self-Care Behaviors™: healthy eating, being active, taking medications, monitoring, healthy coping, problem solving, and reducing risks. An interdisciplinary team approach, led by a diabetes educator, is used to furnish diabetes education. Diabetes educators represent a variety of health disciplines, including registered and advanced practice nurses, registered dietitian/nutritionists, pharmacists, physicians, exercise physiologists, mental health care professionals, optometrists, dentists, occupational therapists, physical therapists, and others.
The benefits of DSME are many, not only to the PWD, but also to the ACO and to healthcare payers. The intervention has been shown to be cost-effective by reducing hospital admissions and readmissions1-3 as well as estimated lifetime healthcare costs related to a lower risk for complications.6 DSME improves glycated hemoglobin (A1C) by as much as 1% in people with type 2 diabetes.7-12 A systematic review of the literature by the AADE on the effectiveness of DSME found robust data demonstrating that engagement in diabetes self-management education results in a statistically significant decrease in A1C levels.13
Besides this important reduction, diabetes education has a positive effect on other clinical, psychosocial, and behavioral aspects of diabetes, which positively affect the attainment of quality measures that the ACO seeks to meet under the MSSP. Research studies have consistently reported that DSME:
• Reduces the onset and/or advancement of diabetes complications14,15
• Improves quality of life10,16-18 and lifestyle behaviors such as healthful eating and engaging in regular physical activity19
• Enhances self-efficacy and empowerment20 • Increases healthy coping21
• Decreases diabetes-related distress7,22 and depression23,24
Given the projection that 1 in 3 individuals will develop type 2 diabetes by 2050,6 it has been postulated that the US healthcare system will be unable to afford the costs of diabetes care unless incidence rates and diabetes-related complications are reduced. It is clear that a key way to reduce costs and improve diabetes quality measures is via DSME. One could posit that the aforementioned benefits are realized because DSME is guided by the best available scientific evidence, incorporates the needs, goals, and life experiences of the person with or at risk of diabetes, includes the latest technology such as continuous subcutaneous insulin and continuous glucose monitoring, and addresses the range of costly comorbid conditions such as hypertension, hyperlipidemia, and renal dysfunction. Based on this and other data, the American Diabetes Association (ADA), the American Association of Diabetes Educators (AADE), and the Academy of Nutrition and Dietetics published a joint position statement in which it is recommended that all PWDs receive DSME at diagnosis and as needed, thereafter,25 as it is a key part of the medical management continuum of PWDs throughout their lifetime. Healthy People 2020 and CDC each recommend that PWDs should receive formal diabetes education.
The Medicare Diabetes Self-Management Training (DSMT) Benefit
Armed with this cost-effective data, Medicare implemented a benefit, known as diabetes self-management training or DSMT, under Part B in the year 2000 for beneficiaries with type 1, type 2, and gestational diabetes. Medicare refers to its benefit as “training” rather than “education,” hence the term DSMT rather than DSME. The initial benefit consists of 9 hours of group and 1 hour of individual DSMT in 12 consecutive months, and 2 hours of follow-up training every year, thereafter, to further insure positive patient outcomes and healthcare cost savings. Approved places of services include a variety of outpatient settings that are typically within the ACO network (eg, hospitals, clinics, physician practices, etc.). To be eligible for Medicare reimbursement, the DSMT program must first achieve either AADE Diabetes Education Accreditation or ADA Education Program Recognition. To achieve and maintain this gold standard of quality, the program’s sponsoring organization/individual must show initial and ongoing proof that its DSME policies, procedures, and program design adhere to 10 National Standards of DSME,4 and to other key reporting and continuous quality improvement activities.
Quality Measures of the Medicare Shared Savings Program
ACOs are required to accurately report quality data that are used to assess their quality performance. In addition, an ACO participating in the MSSP will share in the Medicare cost savings it generates if it meets and reports 34 quality measures in 4 domains. A summary of the MSSP-specific measures in the 2016 quality reporting year that diabetes educators can positively influence are summarized in TABLE 1; those involving cardiovascular disease, hypertension, and depression are included, as these conditions are significant comorbidities of diabetes that educators address in DSME. The goal of implementing diabetes measures is to evaluate and improve the quality of care for PWDs cared for by an ACO. These patients, who account for a significant proportion of Medicare beneficiaries in the ACO, experience high morbidity as well as higher rates of emotional stress and depression. This leads to frequent hospital admissions, resulting in high costs for both the PWDs and the ACO. It is well documented that this vulnerable population needs efficient, coordinated, patient-centered, whole-person care management across the continuum. ACOs create infrastructures to furnish this, and promote strong provider and multidisciplinary healthcare team support—all essential ingredients for effective chronic disease management. Research shows that effective care management can lower the risk of hospital admission for PWDs.26 Diabetes educators possess what I call the S.C.R.I.P.T.s, which are required characteristics to be key members of the ACO’s healthcare teams.
S = Skills C = Competencies R = Resources I = Inventiveness P = Proficiency T = Training
These characteristics are especially evident in educators who have achieved the Certified Diabetes Educator (CDE) or Board Certified-Advanced Diabetes Management (BC-ADM) credential.
Diabetes Educators on the Care Coordinator Teams in ACOs
As payment models change from a FFS model to risk-sharing models that reward quality and efficiency, ACOs must strive to meet 4 key goals. These goals are actually the key drivers that impact their bottom-line financial success:
1. Reduce unnecessary, duplicate, and expensive, but preventable services in order to reduce costs
2. Maximize the patient experience
3. Maximize population health
4. Maximize revenue
Enter, the care coordinator teams (CCTs). Many in the health industry consider these team members the most important medical professionals within a large healthcare system such as an ACO. Why? To meet these goals/drivers, consistent patient care coordination is required when patients access the comprehensive array of health services spanning all levels and intensity of care in the different stand-alone ACO entities. It is not far-fetched that 1 ACO patient will access all 7 basic service categories across the care continuum in the stages of his/her life: wellness/prevention, ambulatory care, acute hospital care, extended care, home care, outreach/community services, and transitional care. The more services accessed, the more care coordination is required to ensure that the goals of the ACO are met in the land of healthcare reform. In the pre-ACA era, care was more “reactive,” meaning, it was dispensed primarily when it was sought by the patient, not when initiated by care coordinators or providers. In the ACA era, care is much more “proactive,” meaning it is typically, and frequently, initiated by the care coordinator team to increase the patient’s health over his/her lifespan. I describe the work of the CCT as “connecting the health care dots” on behalf of the patient.
Diabetes educators understand this framework well, as DSME also requires ongoing coordination across these service categories throughout the lives of PWDs. Educators also understand the bottom-line impact of the ACO’s 4 key business drivers outlined above, as these drivers directly affect the financial success of their DSME programs.
Diabetes educators also support and help fulfill the 3 goals of the ACA known as the “Triple Aim.” The FIGURE depicts the Triple Aim and how DSME itself supports these key goals. The ACO can thus optimize their own business goals via 2 cost-efficient initiatives: implement DSME programs within the ACO entities (especially in medical homes and physician practices), and include diabetes educators as members of the ACO’s CCTs.
Care coordinators (CCs) are specially trained medical professionals who help patients navigate the complicated care continuum. For PWDs, reducing barriers to adherence to his/her management plan, and closing care gaps, are especially important due to the many diabetes comorbidities and life challenges these patients are likely to face. TABLE 2 summarizes the responsibilities of CCs in large health systems such as ACOs. Diabetes educators have the training, skills, and experience to enhance the effectiveness of these teams. This is accomplished by assuming these responsibilities for patients with chronic disease and furnishing DSME for PWDs and prediabetes.
In Summary: Diabetes Educators’ Multiple Roles in ACOs
ACOs continue to transform and expand their infrastructure to address gaps in diabetes care and improve quality measures in order to maximize value-based reimbursement and increase their patient and provider base. Diabetes educators are well positioned to aid ACOs in achieving these business and financial goals. They have the skills and training to furnish cost-effective DSME, to be members of the ACO’s care coordinator teams, and to help these organizations not only meet their diabetes quality measures, but other key measures, as well. Borrowing from our industry’s often used terms to describe many interventions such as “cost-effective” and “proven,” I would ask the reader to note that diabetes educators, themselves, are “cost-effective” and “proven” to be valuable assets to large health systems that offer a wide array of medical and preventive care services.