A panel of experts discuss considerations in insurance coverage for the treatment of patients with diabetes.
Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: Endocrinologists and diabetologists need to manage the hyperglycemia. Nephrologists are identified as a group for hypertension, even though they never want to take that responsibility. There’s a group of people who want to do lipidology. This used to be endocrinologists, but it morphed into the cardiology world. It’s about time for it all to change in terms of management. We see the person. We can’t say hyperglycemia or hypotension and not treat the others. When I was president at AACE [American Association of Clinical Endocrinology], we changed our guidelines from the management of diabetes to a comprehensive approach to managing the patient, addressing how we see risk factors. It’s getting more complicated as we go forward. The earlier we start, the less complication we’ll have because uncontrolled high blood pressure with hyperglycemia can cause more retinopathy, kidney disease, and other complications in the body. What if the insurance company sees a patient like this, and [the patient] gets 7 medications on the first visit? Is that going to cause a problem?
Jaime Murillo, MD: It shouldn’t. One thing insurance companies are very careful about is being seen as interfering in the care of patients or dictating care. There’s a separation between clinical adjustment and managed care. That’s 1 part. Eugene, you were talking about how you holistically manage the patient. You were asking [about the roles of] the primary care doctor, the specialist, the cardiologist, and so on. What incentivizes doctors to take care of their patients? By the same token, what are the barriers that prevent them from being able to spend time screening their patient with hyperglycemia and looking for other diseases? “It’s been 15 minutes. I need to run. The next patient is waiting for me.” Can we change that system? Insurance companies have an opportunity to partner because it’s not just 1 stakeholder that can change the whole system. It’s about partnering with health systems, doctors, hospitals, and other stakeholders on how we can change the disease so that people can be treated, as they should be. You’ve seen some of the scenarios where value-based care comes into play. It’s not about how many patients you can see in an hour. It’s about the best way you can treat this patient so we can prevent complications down the road and lower the total cost of care.
Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: It would be wonderful if you could do that. Eugene?
Eugene E. Wright Jr, MD: You hit on something near and dear to me in performance improvement. One way to do that is to first make chronic kidney disease or type 2 diabetes a priority. Making it a priority means that you engage all the stakeholders. Insurance companies, health systems, clinicians, physicians, and patients should be engaged in that process. I like to use the performance improvement model, where we set smart goals—specific, measurable, achievable, and realistic. We have a model for doing that. When we get to that, we have to go into practice and think of our readiness assessment. Collect your data, and know where we are now. How do you know where you’re going unless you know where you start? We start with a readiness assessment. We have to prioritize the patient experience because the patients are very important. They can make or break any performance improvement plan, particularly as it relates to early recognition and treatment. I apologize for going on so long, but this is what I do.
We have to use validated, endorsed guidelines, so the cardiologists, endocrinologists, and nephrologists are in agreement that we’re going to use this approach. It needs to be the primary care lead, but it needs to be supported by our specialist colleagues. I’d like to see us leverage the IT [information systems that we have to identify patients at risk. We have a way of doing that, and we’ve done that with other disease states. I’d like to see us do some community outreach. This is something that the whole team can do. Or we can raise awareness, education, and engagement through community outreach. Then we need to do the appropriate screening.
Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: Here’s the issue. A lot of insurance companies aren’t willing to pay for that screening and early identification. It’s not there. It’s supposedly not part of their mandate. Maybe that also has to change—the way insurance companies approach it. I love to hear what you said. You go to some health care systems or clinics where the doctor is allowed to address only 1 medical condition. You’ve got 6, 8, 10 minutes with the patient, and you can address only 1 disease. Most of the time, it’s always next on the EMR [electronic medical record]. If the patient comes to manage their hyperglycemia but their blood pressure is high, then you need to make another appointment to come back. That has to do with reimbursement for time. That comes back to the insurance company’s point of view. We can go on and on. Obviously, we need to be on both sides of the fence. But the best way to go forward is to teach all of us to address those risk factors right there. Then when you see the patient, manage them right away. That’s the only way we’ll be able to make a big change for the patient from the start.
Transcript edited for clarity.