Alvin C. Powers, Jason A. Wexler, Robert W. Lash, Meredith C. Dyer,
Mila N. Becker, and Robert A. Vigersky
In the United States, slightly more than half of all adults
with diabetes receive guideline-consistent care.1 A
smaller proportion has adequate cardiovascular risk factor
control.2 Current care of individuals with diabetes
and its complications and comorbidities exemplifies
many of the challenges facing the U.S. healthcare system.3 Based on the care costs relative to the outcomes achieved, Americans deserve greater value for our
Acknowledging the convergence of the diabetes epidemic
and the passage of the Affordable Care Act (ACA),
the Endocrine Society (ES) seized the opportunity to convene
a Washington, DC, Summit on September 12, 2014,
to explore the law’s impact on patients with diabetes. Summit
attendees and speakers included leading diabetes
stakeholders, patient advocacy and community-based
groups, health plans, research institutions, federal agencies,
and policy makers. The agenda featured potential
policy solutions as well as challenges and opportunities
resulting from ACA implementation. In the following
paragraphs, the ES briefly summarizes the proceedings.
Examples of ACA’s Implementation on
Although the full effect of the ACA’s impact on diabetes
care is still being determined, several benefits and challenges
are already clear. Improved access has lowered the barrier for individuals with diabetes to receive care. One
study found a 23% increase in Medicaid patients diagnosed
with diabetes in states that adopted ACA Medicaid
expansion, vs a 0.4% increase in states that did not.4
Given that approximately 25% of Americans with diabetes
are undiagnosed and earlier diagnosis and treatment
reduce long-term complications, this increase is evidence
of progress toward the central goals of the ACA—expanded
access to improve care quality and outcomes. This
report mirrored prior observations showing that more individuals
were diagnosed with diabetes when medical coverage
became available.5 One challenge from expanded
access is exacerbation of the existing problem of the demand
exceeding the supply of available providers (both
primary care and diabetes specialists).
The ACA also supports important new research initiatives
aimed at transforming diabetes care delivery. For
example, the ACA authorized the Patient-Centered Outcomes
Research Institute (PCORI), which supports comparative
clinical effectiveness research and emphasizes engagement
of patients and other stakeholders in research.
PCORI currently supports more than 15 diabetes-related
research projects aimed at improving healthcare systems
and diabetes health disparities. The ACA also authorized
the Cures Acceleration Network (CAN) within the National
Institutes of Health to speed development of new
diagnostics and therapeutics and remove barriers to translation
between discovery and clinical trials. The relevance of CAN to many diabetes-related technologies and needs
Key Items and Policy Recommendations
From ES Summit
Discussion and ES policy recommendations from the Summit
center on three major areas: care organization and
processes, financing reform tied to quality enhancement,
and promotion of new technology and discoveries.
Care organization and processes
Diabetes patients may have multiple medical comorbidities
and often have a diverse set of independently functioning
practitioners treating them. Accordingly, a fundamental
challenge addressed at the Summit was how to
transform multidisciplinary care teams to provide optimal,
coordinated diabetes care. All proposed models featured
a care team whose goal is providing nonduplicative,
continuous, comprehensive, and timely care. This care emphasizes
hyperglycemic control, prevention of hypoglycemia,
cardiovascular risk reduction, and other aspects of
patient self-management to manage comorbidities. Models
must move beyond current case management. Patientcentered
medical homes, either specific to patients with
diabetes or more comprehensive, were seen as a promising
model, but evaluation before widespread adoption is critical.
Questions remain as to whether such approaches will
have sufficient resources to provide access to the type of
diabetes care that improves patient outcomes. Reliance on
endocrinologists in any care model is a challenge because
demand exceeds supply and the discipline is not growing
as fast as the patient population.6 Likewise, greater use
of primary care physicians (PCPs) in the role of care coordinator
is problematic because the PCP supply also lags
Financing reform tied to quality enhancement
For a well-coordinated, sustainable multidisciplinary
team approach to diabetes care, Summit speakers advocated
for payment reform tied to quality measurement.
Shortcomings in the present payment system include rewards
for volume over value from fee-for-service payment,
poor compensation for cognitive-oriented services,
and no compensation or incentives for communication
between patients and providers and among providers. Although
several options for payment reform were discussed,
all stressed the need to tie outcomes to resource
allocation. Promising attractive options were: 1) risk-adjusted,
per-patient payment, with incentives for achieving
desired intermediate outcomes, such as unnecessary hospitalizations,
with a reduction in overall costs; and 2) a condition-based payment system that provides greater
flexibility than the present system for services delivered to
patients with diabetes while holding providers accountable
for avoidable costs and outcomes. Some argued that
pay-for-performance could be extended to patients. If
healthy behaviors were rewarded, there could be reduced
reliance on medical care, potential cost savings, and a net
benefit to patients exercising self-management skills.
Promotion of new technology and discoveries
ACA-related requirements for information technology
and electronic health records are particularly applicable to
patients with diabetes because many patients have comorbidities
and require management by multiple providers.
Challenges involving implementation of new technologies
such as insulin infusion devices and continuous glucose
monitoring systems include cost and determination of appropriate
use. Speakers urged rational use of emerging
technologies, balancing the impact of new technology
with the need for comparative effectiveness research in
appropriate populations. Prevention of hypoglycemia, an
adverse event now responsible for more hospital admissions
than hyperglycemia, was cited as a major goal of
these new technologies.
Conclusions About the Summit and ES
Diabetes outcomes and care models resulting from
ACA implementation should be monitored systematically.
Early data suggest that the ACA is increasing diabetes
detection and diagnosis. Other ACA effects need
to be monitored for lasting impact on outcomes and
value to diabetes care.
Continued investment in clinical and translational research
on new diabetes care models should encourage
multidisciplinary teams, telemedicine, and electronic
communication between providers and patients. The
ES recommends training more endocrinologists and
midlevel providers to adequately support such care
teams. The ES supports pilot studies by payers that feature
team-based approaches to improving diabetes care
by assisting the patient in achieving glycemic control,
lessening hypoglycemic incidents, and preventing or
managing comorbid conditions.
Reimbursement should be reformed to link payments to
the provision of integrated, comprehensive, guidelinecompliant
care and the achievement of appropriate intermediate
and longer-term outcomes such as reductions
in micro- and macrovascular complications.
Prevention and management of diabetes and prediabetes
should be better integrated into health systems and other settings, such as community- and employer-based
Federal and other funding for research by the National
Institutes of Health, the Agency for Healthcare Research
and Quality, and the PCORI should be increased
to address gaps in knowledge about diabetes care and
promote the development of next-generation therapy
Review and approval by the Food and Drug Administration
(FDA) for treatments that address unmet needs
in diabetes care should be accelerated. The ES recommends
that the Centers for Medicare and Medicaid Services
(CMS) and the FDA utilize a parallel review process
to improve access to new diabetes therapies. This
type of collaboration can lead to more rapid development
of CMS coverage policies and funding for new
technologies, including mobile and self-help tools for
patients with diabetes.
We thank the speakers at the Summit who presented unpublished
information and allowed the authors to use their ideas and
thoughts in assembling this document. We also thank the Endocrine
Society’s Advocacy and Public Affairs Core Committee for its contributions in reviewing this manuscript, as well as
Avalere Health for its contributions in organizing this Summit.
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