A former president of the American Association of Diabetes Educators addresses the need to remodel diabetes self-management education and support, to create a reimbursement system that better meets the needs of today's providers and patients.
Societal trends are converging to raise the question, is it time to remodel diabetes self-management education and support (DSMES)? These trends include the related epidemics of obesity, prediabetes, and type 2 diabetes, which we know are progressive and frequently occur with comorbidities and complications that demand increasingly complex management. This management occurs most often in primary care, where the average appointment is just over 20 minutes.1 Healthcare delivery is evolving toward value-based care and payment structures, with a focus on improving primary care delivery and patient engagement. The public is growing accustomed to easily accessible, 24/7 services for banking, shopping, and other services that lead them to expect the same for their healthcare. Lastly, and importantly, technology is enabling an array of digital health solutions.
In 1997 Medicare authorized expanded coverage for Diabetes Self-Management Training, the term CMS uses for the DSMES benefit, for all people with a diabetes diagnosis.2 Prior to 1997, this benefit was offered only to people with insulin-requiring diabetes. To be eligible for Medicare reimbursement, DSMES programs must be recognized by the American Association of Diabetes Educators (AADE) Diabetes Education Accreditation Program3 or the American Diabetes Association (ADA) Education Recognition Program.4 These are the sole national accrediting organizations designated by CMS for this benefit.
DSMES is defined as the ongoing process of facilitating the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage on an ongoing basis.5 This Medicare benefit was originally designed almost 2 decades ago to reimburse for a formal curriculum-based program typically conducted at a hospital outpatient or healthcare facility. Over the years, CMS has made minimal changes to the design and structure of this benefit, although legislation to revise the program has been introduced several times. Currently, there is bipartisan legislation to make changes in the structure and coverage.6 At present, beneficiaries with a confirmed diagnosis of diabetes are eligible for up to 10 program hours of initial education and then 2 hours of service in each subsequent year.5 Private payers often follow Medicare’s guidelines for DSMES coverage.
High Effectiveness, Low Usage
DSMES has been shown to improve glycated hemoglobin (A1C) by as much as 1%. In addition, DSMES improves other clinical factors and quality of life while reducing hospitalizations and healthcare costs and minimizes the onset and/or advancement of diabetes complications.2,5,7 The ADA’s Standards of Medical Care in Diabetes recommends that all individuals with diabetes receive DSMES at diagnosis and as needed.7 However, the DSMES benefit remains woefully underused by Medicare beneficiaries and private payers, with estimates of under 10%.5,7,9
The current delivery model for DSMES has inherent barriers that are becoming more significant because of the noted societal trends that play a role in low usage. Primary care providers lack knowledge and understanding of this benefit and often do not adequately refer people with diabetes for the service. If the requisite referral is made to what is often called diabetes education, the service may be provided in a location apart from that of an individual’s other healthcare providers
and may be offered by providers with whom they are unfamiliar. Individuals with diabetes may not have an understanding of DSMES or its value in their diabetes care. Add to this mix the potential for co-pays, deductible reimbursements, time away from work, and travel costs. Lastly, in a curriculum-based, once-and-done education program delivered, in most instances, in a group setting, diabetes educators lack the capacity to optimally individualize peoples’ care and management.
Time to Remodel DSMES
In support of a new model for DSMES more in line with the current understanding of the needs of adults with diabetes, a 2015 Joint Position Statement from the ADA, the AADE, and the Academy of Nutrition and Dietetics outlined an algorithm for the 4 critical junctures when DSMES should occur: at diagnosis, annually, when complicating factors arise, and during transitions in life and care.7 Action steps for each critical juncture are also provided. This statement details why the DSMES benefit as designed is no longer in concert with the collective evidence that people with diabetes need education, along with changes in management and support throughout their lives, to match their ever-changing life and care needs to achieve positive outcomes.2,5,7
Although CMS regulations have changed mini- mally, diabetes educators, healthcare systems, and healthcare enterprises have adapted where and how DSMES is delivered, and services are increasingly integrated into primary care settings, Federally Qualified Health Centers, patient-cen- tered medical homes, and other new models of care. Technology-based solutions are increasingly common and can serve diverse needs, including reaching patients in rural areas.
Current State of Clinical Outcomes
Though the goals for glycemic, lipid, and hypertension control are well known, and healthcare providers have more tools than ever in their armamentarium, 33% to 49% of people with diabetes don’t meet these targets, and only 14% meet the targets for all 3 measures and avoiding smoking.10 More recent Healthcare Effectiveness Data and Information Set figures show that only 40% of people covered by a health maintenance organization and 30% of people covered by a government healthcare plan achieve the A1C goal of less than 7% with no change seen over the past decade.11 Real-world trends in glycemic-lowering medication demonstrate limited use of and intensification with newer such medications,12 and real-world medication adherence and persistence are significant.13From Isolation to Integration in the Care Continuum
We’ve repeatedly observed in results from multisite studies funded by the National Institutes of Health that frequent and consistent education, training, and behavioral and lifestyle change facilitation and support provided by healthcare providers with diabetes care expertise improve clinical outcomes and, in some cases, cost effectiveness of care. Over the past decade, diabetes educators and others have tested the delivery of DSMES or innovative models in new delivery locations and formats including technology-based ones. (Coverage on SP452-SP455) details several of these use cases.)
Advancing the Roles and Use of the Diabetes Educator
Beyond the need to remodel DSMES and delivery models, it may also be time for an evolution in the specialty of diabetes education, including the name diabetes educator, and perhaps the professional association, AADE. As part of its current strategic plan, AADE has developed a vision through 2033 and within this effort has asked these questions. An estimated 20,000 diabetes educators hold the Certified Diabetes Educators (CDE) credential.14 CDEs all hold a registration and/or license in their primary discipline of nursing, dietetics, pharmacy, behavioral health, exercise science, or other areas. Board Certified-Advanced Diabetes Management is the other advanced credential in the field.15 An increasing number of diabetes educators have earned advanced practice credentials, such as nurse practitioner, physician’s assistant, and clinical nurse specialist, and in some states, these professionals have prescriptive authority. Doctors of pharmacy may work under cooperative medical management agreements.
Other credentialed diabetes educators have within their state-based scopes of practice the knowledge and capabilities to work alongside providers with prescriptive authority to titrate glycemic control medications and possibly others based on prescriber-approved algorithms. This role fits naturally with delivering education, management, and support. Enabling these healthcare providers to practice at the top of their scope of practice has the potential for healthcare systems to cost-effectively build on value- based care models striving to achieve the triple aims of healthcare.
Beyond delivering direct care, diabetes educators have and continue to take on roles in various types of organizations and businesses that include program management, risk stratification, population health management, case management and coordination, technology-enabled care delivery systems, and supervision of paraprofessionals such as community health workers, lifestyle coaches, and others.
Impetus to Remodel DSMES
We now have all the impetus we need to remodel DSMES to increase usage and affect individuals’ short-and long-term health and the healthcare system at large. For starters, it’s critical to integrate the ADA standards of care, guaranteeing that all people with diabetes receive education and support8 in the care continuum, and to deliver it based on the Joint Position Statement algorithm.7,16 With the use of newer models of care, a laser focus on increasing the use of and improvements in primary care practice, and new pay-for-performance payment models like those within Medicare’s Quality Payment Program, it makes sense to integrate practitioners with diabetes expertise into healthcare delivery systems to offer a variety of results-proven innovative models of DSMES rather than isolate them.
Taking the integration of DSMES into the care continuum a step further, digital health solutions show promise. A recent publication explains the potential: “The anytime anywhere capabilities of digital technology support the delivery of auto- mated, personalized, individualized content and coaching at the right time in the right way at the right place (while living life with diabetes), thus providing a timely nudge encouraging ongoing, informed self-management.”17
Evidence is mounting for the clinical effectiveness of technology-enabled solutions, particularly for time- and care-intensive chronic conditions like diabetes. In a 2017 systematic review, participants in the majority of studies (18 of 25) showed signif- icant A1C improvement.18 This review identified 4 key elements that were incorporated into the most effective interventions, including (1) 2-way communication, (2) analyzed patient-generated health data, (3) tailored education, and (4) individualized feedback. The authors refer to this as a technology-enabled self-management feedback loop that connects people with their healthcare providers. With this and other information, the 2018 ADA standards of care for the first time recognized emerging evidence of technology-enabled solutions to deliver DSMES.8 The Figure offers considerations for healthcare providers and systems when choosing a digital health solution.
Two currently available diabetes care digital health solutions from for-profit entities, One Drop and Livongo, have received DSMES recognition (ADA)19 or accreditation (AADE),20 respectively. However, neither presently bills Medicare for its service because of lack of coverage for online platforms or virtual DSMES. Another digital health solution entity, Welldoc, has licensed AADE’s DSMES curriculum and has integrated it into its BlueStar FDA-cleared mobile medical app within a 12-week patient journey,21 and translated into Spanish.
Although the hurdles of reimbursement and coverage of services will not disappear quickly, the evolution to new models of care and the increased willingness of private payers and Medicare to implement and allow billing for connected care solutions will assist this transition. In recent years, even Medicare is revising previously rigid definitions of telehealth and adding new codes to allow for services like chronic care management (Current Procedural Terminology [CPT] code 99490)22 and remote patient monitoring, including glucose monitoring (unbundled CPT code 99091).23 Using remote patient monitoring is considered an improvement activity under the Medicare Merit-based Incentive Payment System. As part of the 2018 federal budget agreement, Medicare will make additional changes to its telehealth and telemedicine regulations.24 In addition, the CMS proposed 2019 Medicare Physician Fee Schedule pushes the envelope of reimbursement for telehealth and remote patient monitoring even further.25
In conclusion, the answer to the central question posed here is yes. It is time to remodel DSMES. This includes revamping the design of the Medicare benefit and the payment structure for coverage to better mesh with the current and impending needs of healthcare delivery and primary care providers. More important, we need innovative and successful models of care that meet the needs of people with these conditions and their caregivers. Reflexively, these changes will necessitate changes in the roles of diabetes educators and perhaps lead to a more accurate name for these increasingly valuable healthcare providers, to improve diabetes outcomes while achieving costs savings.
Hope S. Warshaw, MMSc, RD, CDE, BC-ADM, owns Hope Warshaw Associates, LLC, a diabetes and nutrition consultancy based in Asheville, North Carolina. She served as president of AADE during 2016.
Warshaw serves as a consultant to Welldoc, Inc.References