For several years, the American Association of Diabetes Educators has been collecting evidence that shows that diabetes self-management training programs meeting its accreditation standards warrant coverage by public and private insurers.
Expansion of insurance coverage for diabetes self-management training is recommended in light of increasing diabetes prevalence, escalating associated costs, and success of DEAP programs. For several years, the American Association of Diabetes Educators (AADE) has been collecting and analyzing clinical outcomes and behavioral data of patients with diabetes participating in diabetes self-management training (DSMT)1 programs accredited by the AADE Diabetes Education Accreditation Program (DEAP). These data provide a large body of evidence (unpublished) that supports the notion that participating in an accredited DSMT program may not only improve general health outcomes associated with positive diabetes management, but may also lead to a substantial reduction in glycated hemoglobin (A1C) levels, an indicator of controlled blood sugar management. This underscores the need to re-examine and expand insurance coverage of DSMT programs by both public and private insurers.
AADE is one of two National Accreditation Organizations (NAOs) for DSMT, the other being the American Diabetes Association (ADA). As an NAO, AADE has the responsibility of accrediting DSMT programs to allow them to bill Medicare for their DSMT services. Every year, data are collected from the DSMT programs by AADE through the annual status report requirements. AADE has been gathering data since first becoming an NAO in 2009. Participants in a Medicare-certified DSMT program are allowed up to 10 hours in the first 12-month period. Because this program is patient centered, not all participants choose to utilize or feel they need all 10 hours. The hours utilized are between the patient and their diabetes educator. Some patients do complete all 10 hours.
Over the past few years, more than 700 DEAP programs, i.e., AADE-accredited DSMT programs, have served over 160,000 patients with diabetes; during this time, the individual programs have generally served, on average, a few hundred patients annually. DEAP programs collect both clinical and behavioral outcomes measures. Every year they submit the average value of the data collected for their patients’ pre-education and post-education outcomes to AADE. The behavioral outcomes that are collected include achievement of goals set on each of the AADE7 self-care behaviors™ 2 and compliance with annual foot exam and dilated eye exam recommendations. The patients self-report on all of the behavioral outcomes. The clinical outcomes that are collected include A1C (%),body mass index or BMI (kg/m²), blood pressure (mm Hg), and weight (lbs).
The AADE7 self-care behaviors™ are 7 areas that diabetes educators have identified as key areas patients should learn to address and improve upon in order to better manage diabetes.2 These behavioral outcomes include heathy eating, being active, monitoring, taking medication, problem solving, reducing risks and healthy coping. While participating in DEAP programs, patients learn many strategies they should incorporate daily to help them monitor their blood sugar levels and make adjustments in food and activity for the best outcomes. They set nutrition goals, develop an eating plan, read nutrition labels and learn how to count carbohydrates, which impact blood sugar. Patients learn how being more physically active can help them maintain and control blood sugar levels, as well as lower cholesterol and blood pressure. They receive information about a number of medications that may help reduce the risk of some of the complications associated with diabetes including aspirin, blood pressure medication and cholesterol medication.2
Through participation in DEAP programs, patients with diabetes are also educated about how to problem solve, reduce other health risks and develop healthy coping skills. They develop a variety of strategies for dealing with unforeseen problems and learn to plan for the unexpected. Patients also learn how to reduce their risks of other diabetes-related health complications and develop skills on how to cope with these new life challenges that diabetes presents to them on a daily and lifelong basis.2
Patients enrolled in DEAP programs also self-report on compliance with annual foot exam and dilated eye exam recommendations. Annual dilated eye exams may reveal other health problems or risks for serious complications due to diabetes, such as retinopathy. If detected sufficiently early, microvascular changes in the eye can usually be reversed through changes in nutrition, exercise and medication.3 Annual foot exams can help prevent serious complications from nerve damage or neuropathy and can provide early detection of ulcers and foot deformities.4
Particularly encouraging is an apparent substantial reduction in the average hemoglobin A1C (A1C) values post-education (as compared to pre-education) that has been reflected in the data submitted to AADE by the DEAP programs year after year; formal analysis of these data by AADE is underway. The A1C test provides information about a patient’s average blood glucose level in the past 3 months.5 When glucose attaches to hemoglobin, the hemoglobin becomes glycated. Reported as a percentage, the A1C test measures the amount of glycated hemoglobin and indicates the patient’s average blood glucose level for the prior 3 months. Higher A1C percentages indicate higher average blood glucose levels. The National Institutes of Health define a normal A1C value as below 5.7%..5 Elevated A1C levels lead to microvascular health problems associated with diabetes such as kidney failure, limb amputation and blindness. By lowering A1C levels, individual patients can reduce their risk of experiencing these complications. In fact, lowering A1C levels by even 1% has been linked to reducing the risk of microvascular complications by 37% and reducing the risk of myocardial infarction by 14%.6 The ADA describes tight control as an A1C of 7% or less.7
The CDC estimates that 29.1 million people in the United States, or 9.3% of the population, are living with diabetes. Of those, 21 million people have been diagnosed, and 8.1 million people are living with diabetes and do not realize it.8 The rise in the number of people being diagnosed with diabetes has led to a corresponding rise in diabetes-related health care costs. The ADA stimates that in 2012 there was $176 billion in direct medical costs related to diabetes in the United States.6
The person with diabetes is personally impacted by these costs. While diabetes is a medical condition that can be managed, managing it costs money in terms of insulin, supplies and additional physician visits and screenings. In 2012, persons with diabetes in the United States had medical expenditures which were 2.3 times higher than those persons who did not have diabetes.6
Not managing diabetes correctly is even more expensive than proper management. The health problems and complications associated with diabetes are numerous and can be devastating both personally and financially. In the absence of proper health care utilization and self-management, diabetes can lead to heart disease, stroke, limb amputations, blindness and kidney failure. The costs associated with not knowing how to self-manage one’s diabetes are clearly expensive in terms of the effects on one’s health, quality of life and life expectancy.
Indirect costs associated with diabetes have also risen. The CDC estimates indirect costs related to diabetes in the United States at $69 billion in premature mortality, disability payments, absenteeism and lost productivity in the workplace.8
Both the monetary costs and health costs associated with diabetes can be reduced by careful management of blood glucose levels. Learning how to manage one’s diabetes and reduce blood glucose levels is not easy, especially for a patient who is newly diagnosed and may be overwhelmed by the diagnosis and its demands. However, DSMT programs, such as those accredited by AADE (DEAP programs), can play a vital role in helping patients control their blood sugars and maintain their health while also reducing the direct and indirect monetary costs associated with diabetes.
Recognizing the importance of self-management of diabetes, Medicare began reimbursing for participation in outpatient diabetes self-management training (DSMT) in 2000. As mentioned earlier, to qualify for Medicare reimbursement, DSMT programs must be either accredited by AADE or recognized by ADA. In order for DSMT program providers to be accredited or recognized by AADE or ADA, they are required to meet the National Standards for Diabetes Self-Management Education and Support.9
Medicare Part B reimburses for a total of 10 hours of training (DSMT) the first year after a patient qualifies. The 10 hours of training in the first year include 1 hour of personal training and 9 hours of small group training. Medicare will also reimburse 2 hours of training per year after the first year. For patients to qualify for reimbursement of their participation in these programs, they must be diagnosed with diabetes and be referred to an accredited or recognized DSMT program by a qualified provider. These programs are offered in a variety of outpatient settings including physician offices, hospital outpatient departments, federally qualified health centers, health department’s clinics, community centers, pharmacies and other community sites.10
diabetes self-management training services. A 2015 report stated that private insurers in 44 states and the District of Columbia are required by state legislation to provide coverage for diabetes self-management training programs, and that only Alabama, Arizona, Delaware, Idaho, North Dakota and Ohio do not require private insurers to cover this training.6
While passage of the Affordable Care Act in 2010 emphasized coverage of preventive services, the Act does not require coverage of DSMT nor does it consider DSMT a “free” benefit. Furthermore, the Act does not require DSMT to be 100% covered by insurance nor does it eliminate co-pays for DSMT. The Act gives states the responsibility and flexibility of modifying the DSMT benefit offered. States can modify the benefit or expand or limit the benefit, e.g., by specifying how many hours of training are covered and whether that training has to be completed within a specified time period.11
Despite some reimbursement for DSMT classes by both public and private insurers, utilization of this benefit by patients with diabetes through participation in DSMT programs has been, and continues to be, extremely low.10 Costs and lack of insurance coverage for diabetes self-management training appear to be major contributing factors in this low utilization rate.6
For several years, AADE has been collecting and analyzing clinical outcome and behavioral data of the patients with diabetes who participate in its DEAP programs. As this body of data is now quite large and appears to show an array of benefits associated with DEAP program participation, including substantial reductions in A1C, AADE is now undertaking a formal analysis of these data, and intends to complete this and submit its DEAP program results for publication in a scientific journal soon. The success of the DEAP programs, along with the growth in the number of persons experiencing diabetes onset and the increased financial and health costs associated with diabetes in the United States, indicate that expansion of insurance coverage for diabetes self-management training programs should be given due consideration, because it may serve to reduce costs and increase healthy outcomes.
Catherine A. O'Brian, PhD, and Leslie E. Kolb, MBA, BSN, RN, are with the Department of Science and Practice of the American Association of Diabetes Educators. References
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2. American Association of Diabetes Educators. AADE7TM Self-Care Behaviors. AADE website. https://www.diabeteseducator.org/patient-resources/aade7-self-care-behaviors. Accessed August 31, 2016.
3. American Association of Diabetes Educators. Beyond a yearly eye exam: Educators’ role communicating eye health to patients. AADE website. https://www.diabeteseducator.org/news-publications/aade-blog/aade-blog-details/aade/2015/03/12/beyond-a-yearly-eye-exam-educators-role-communicating-eye-health-to-patients. Accessed August 31, 2016.
4. Iraj B, Khorvash F, Ebneshahidi A, Askari G. Prevention of diabetic foot ulcer. Int J Prev Med. 2013;4(3):373-376.
5. U.S. Department of Health and Human Services. National Institutes of Health. National Institute of Diabetes and Digestive and Kidney Diseases. The A1C test and diabetes. NIDDK website. https://www.niddk.nih.gov/health-information/diabetes/diagnosis-diabetes-prediabetes/a1c-test. Accessed August 31, 2016.
6. Harvard Law School. Center for Health Law & Policy Innovation. Reconsidering cost-sharing for diabetes self-management education: recommendation for policy reform. June 2015. https://www.diabeteseducator.org/docs/default-source/advocacy/reconsidering-cost-sharing-for-dsme-chlpipaths-6-11-2015-(final-draf.pdf?sfvrsn=2 . Accessed August 31, 2016
7. American Diabetes Association. Tight diabetes control. ADA website. http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/tight-diabetes-control.html. Accessed August 31, 2016.
8. Centers for Disease Control and Prevention (CDC). National Diabetes Statistics Report, 2014.CDC website. https://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web. pdf. Accessed August 31, 2016.
9. Haas L, Maryniuk M, Beck J, et al. National standards for diabetes self-management education and support. Diabetes Educ. 2012;38(5):619-629.
10. Strawbridge LM, Lloyd JT, Meadow A, Riley GF, Howell BL. Use of Medicare’s diabetes self-management training benefit. Health Educ Behav. 2015;42(4):530-538.
11. American Association of Diabetes Educators. The Affordable Care Act and individuals with diabetes. ADA website.
https://www.diabeteseducator.org/legacy/_resources/Advocacy/AADE_Affordable_Care_Act_Flyer.pdf. Accessed August 31, 2016.