The Endocrine Society's 97th Annual Meeting & Expo:

Meeting the Needs of a Growing Population with Diabetes

Meeting the burden of diabetes in the US, where almost 30 million people (10% of the total population) has the disease and 42 million sufferers are projected by 2034, was the subject of a presentation given by Daniel Einhorn, MD, FACP, FACE, on March 5, 2015, at the Endocrine Society Annual Meeting in San Diego, California. Dr. Einhorn is Immediate-Past President, American College of Endocrinology; Medical Director, Scripps Whittier Diabetes Institute; and Clinical Professor of Medicine, University of California, San Diego.

Cost of Diabetes Care Is an Overwhelming and Increasing Burden
On March 3, 2015, the Centers for Disease Control and Prevention issued the prevalence of Americans with diabetes at 29.1 million, almost 10% of the population. Eighty-six million citizens aged 20 and older suffer from prediabetes. The prevalence of diabetes is anticipated to reach about 42 million by 2034.

Challenge of Providing Optimal Medical Care Is Not Being Met
The main barrier to guideline-directed care is time constraints: one diabetic patient may take as much time to treat as 10 nondiabetics when between-visit and paperwork are considered, for the same reimbursement and far higher staff overhead. The consequences are that fewer physicians want to treat complex diabetic patients. Many are less interested in conferences on new therapies because they are unable to prescribe them. As Christopher J. O’Connell, of Medtronic, stated in 2007, “We worry that physicians are being dissuaded form giving best practice diabetes care because of the work/time burden. We need to persuade payers to appropriately compensate physicians for time and expertise.” Dr. Einhorn commented, “How healthcare is financed exerts a big impact on access and the ability to provide the best practices.”

Diabetes Working Group: Addressing the Shortfall in Reimbursement for Diabetes Care
In 2009, the Diabetes Working Group, launched by Medtronic, was born of the need to quantify the gap between the cost of providing medical services to patients with complex diabetes issues and reimbursement for that care. The identified gap could then be used to benchmark costs and negotiate with payers.

The group used a standards-of-care economic model to compare provider costs with reimbursement and calculated the gaps in reimbursement. The gap was calculated using the maximum and minimum provider cost estimate, reflecting baseline- and best-case provider time estimates. Dr. Einhorn explained, “Those of us in leadership of medical societies are trying to inform the ongoing policy debate about how to manage complex chronic illnesses like diabetes. This working group and research project was a rare effort to quantify the gap between reimbursement and the cost of delivering care and a rare collaboration among all the relevant societies.”

A Web-based survey of demographics and practice patterns of providers was administered, and standards integrated from the American Diabetes Association, American Association of Clinical Endocrinology, and The Endocrine Society to produce a consolidated set of 28 standards of optimal diabetes care.

A provider matrix of physicians, clinical diabetes educators, registered dietitians, and registered nurses was organized to achieve the standards. Six clinical vignettes (three patients with type 1 diabetes and three with type 2 diabetes) were developed to represent a broad spectrum of patients. Three panels of four to seven diabetes care professionals estimated the minimum and maximum time needed to achieve the standard of care for patients over 1 year.

An expert panel estimated the time needed to start or continue to follow patients using insulin pumps or continuous glucose monitoring. A reimbursement gap was calculated, which was the total reimbursement amount minus total provider costs for the average number of patients seen in a year. 

Findings of the Diabetes Working Group
The group published its findings in Diabetes Care [36(11):3843-3849]. Baseline model results showed a gap between provider costs and reimbursement of $121-$829 per patient per year, depending on specific patient characteristics. Under the best-case scenario, the costs for treating diabetes patients in an average adult practice would exceed reimbursement by over $750,000 yearly.

In an average pediatric practice, costs would exceed reimbursement by over $471,000 yearly. These gaps rose for patients using intensive management technologies such as continuous subcutaneous insulin infusion and continuous glucose monitoring.

Potential solutions

  • Care management: Team-based, shared decision-making; health information technologies to better assist patients n self-management and track blood glucose levels and overall management; electronic prescriptions to monitor medication adherence; patient registries and/or databases to track and trend goal achievement
  • Payment reform: A fee-for-service model, in which billing codes better describe the service being rendered; a patient management fee model (a monthly per-patient payment for all care); a diabetes-focused patient-centered medical home, which encourages care coordination and aligns reimbursement incentives.
  • Raise the number of providers: Forgive educational loans to endocrine fellows, increase the number of endocrine fellowships; encourage diabetes-centric professional societies to promote the positive aspects of working with diabetes patients to medical, nursing, pharmacy, and nutrition students; educate primary care practitioners, including nurse practitioners and physician assistants, on the standards of care and principles of diabetes care.

Models of Diabetes Care Under the Affordable Care Act
No one model has emerged as superior, and models will likely vary widely by region. Multiple new types of models are being tested, which are driven by local champions and trials. Medical societies, such as The Endocrine Society, American Diabetes Association, and American Association of Clinical Endocrinologists; advocacy groups, such as DiaTribe and the Juvenile Diabetes Research Foundation; and medical institutions will likely play an important role.

Dr. Einhorn lamented that the most critical issue facing the community of professionals treating diabetes is the limitation of access to care for patients with complex diabetes management issues. He hopes the gap in reimbursement and provision of guideline-based services closes so that patient needs can be met and research-based practices can become part of everyday diabetes care.

“As healthcare reform is accelerating with the Affordable Care Act,” Dr. Einhorn concluded, “we have an opportunity to make midcourse corrections that will help patient care. Building on many other studies that have shown that delivery of appropriate diabetes care prevents a great deal of attendant medical illness and cost, the research we have performed in the Working Group on Diabetes has helped frame the prevalence and severity of the problem from an economic standpoint.”

Dr. Einhorn asserted, “The majority of the societal costs of diabetes are the consequences of not taking care of the disease in the first place, and incurring the expenses of dialysis, heart disease, amputations, and other comorbidities of diabetes.”

March 13, 2015

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