Is the health insurance industry changing its guidelines regarding paying only for Diabetes Self-Management Education in the setting of a private doctor's office?

I ask the question because this week-end a friend referred to me a person with diabetes who had good private insurance. He said that there are two hospitals near him with Diabetes Education Programs (He lives in Poughkeepsie, NY), but he was told by his insurance company that they would only pay for diabetes education in a private doctor's office. He does go to an endocrinologist in a private office, but the doctor does not have a Diabetes Educator in her office.

As I was reviewing my list serves this morning, I couldn't help but notice this article in "Health Affairs"

Gaps in Quality of Diabetes Care in Internal Medicine Residency Clinics Suggest the Need for Better Ambulatory Care Training

authors:Lorna Lynn (director of Practice Improvement Module research at the American Board of Internal Medicine, in Philadelphia, Pennsylvania), Brian J. Hess (director of research analysis at the American Board of Internal Medicine), Weifeng Weng (health services researcher at the American Board of Internal Medicine), Rebecca S. Lipner (vice president for psychometrics and research analysis at the American Board of Internal Medicine), Eric S. Holmboe (chief medical officer at the American Board of Internal Medicine.)

Here is a quote from the abstract of this article"we compared the quality of medical care provided in sixty-seven US internal medicine residency ambulatory clinics with the quality of care provided by 703 practicing general internists. We found significant quality gaps in process, intermediate outcome, and patient-experience measures. "

http://content.healthaffairs.org/content/31/1/150

I think this might be misconstruing the study being referenced.  This is also discussed at DiabetesInControl.  The study compared care patients recieved in residency clinics to private practice.  This is relevant to me as I see a residency clinic for my primary care.  As far as I can tell, the study looked at the quality of care for patients (like those with diabetes) and found quality gaps, in particular citing such issues as the lack of long-term relationships.  In my case, I am most concerned that perhaps residents may not be getting the best education to deal with the vast numbers of diabetic patients.

My clinic has a consulting educator but also refers to the local diabetes center.   I have not observed any preferencies or priotiries.  The consulting educator provides free sessions for clinic members and is available for private education through the clinic.   A comment by the lead author "Lynn and colleagues called for new residency training programs that emphasize competency-based training and give residents more exposure to ambulatory care settings." It would seem to me that the study author actually suggested that some of the deficiencies observed in residency clinic care could be addressed by giving residents more exposure to the outpatient care one might recieve from a diabetes center or other educator.  Not exactly a criticism of the quality of patient experience.

Thanks for your comments, Brian. I did interpret the study as you did, but it does have me wondering if some insurance companies will be interpreting this or some other study to limit payment for diabetes education to the office of a private physician.  It will be interesting to hear what others have experienced.

Hi All,

It's been proven that big GAPS in quality ambulatory chronic care (with diabetes care being one of the most relevant) VERY often results from practice settings and/or practitioners NOT implementing some or all of the pillars of the evidence-based CHRONIC CARE MODEL.  

I sometimes teach the CCM module at the Johnson and Johnson Diabetes Institute (in Milipitas, CA; www.jjdi.com) as it applies to OP diabetes care.  

We review 5 practice setting case studies that have implemented the CCM in their OP diabetes care areas and how this implementation has significantly closed the gaps in DM care that were pre-identified, and how the gaps were deteriorating care on many levels.

Below is a quick summary of the CCM, which may be helpful to readers:

ABOUT THE CCM RELEVANT TO AMBULATORY DIABETES CARE

Effective OP chronic illness care is characterized by productive interactions between activated patients (as well as their family and caregivers) and a prepared practice team. This care takes place in a health care system that utilizes community resources.

At the level of clinical practice, four areas (4 of th 6 elements of the model) influence the ability to deliver effective chronic illness care.

These are:

1) self-management support

2) delivery system design

3) decision support

4) clinical information systems

The  goal is to deliver care that is safe, effective, timely, patient-centered, efficient and equitable. System changes are checked against these criteria.

The major objectives of each element of the Chronic Care Model are listed below. Each bulleted item is a principle for redesigning care. 

1)  Self-Management Support:

Empower and prepare patients to manage their health and health care.

• Emphasize the patient’s central role in managing their health.
• Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up

• Organize internal and community resources to provide ongoing self-management support to patients.

2) Delivery System Design:

Assure the delivery of effective, efficient clinical care and self-management support.

• Define roles and distribute tasks among team members.

• Use planned interactions to support evidence-based care.
• Provide clinical case management services for complex patients.
• Ensure regular follow-up by the care team.
• Give care that patients understand and that fits with their cultural background.

3) Decision Support:

Promote clinical care that is consistent with scientific evidence and
patient preferences.

• Embed evidence-based guidelines into daily clinical practice.
• Integrate specialist expertise and primary care.

• Use proven provider education methods.
• Share evidence-based guidelines and information with patients to encourage their participation.

4) Clinical Information System:

Organize patient and population data to facilitate efficient and effective care.

• Provide timely reminders for providers and patients.
• Identify relevant subpopulations for proactive care.
• Facilitate individual patient care planning.
• Share information with patients and providers to coordinate care.
• Monitor performance of practice team and care system.

5) Health Care Organization:

Create a culture, organization and mechanisms that promote
safe, high quality care.

• Visibly support improvement at all levels of the organization, beginning with the senior leader.
• Promote effective improvement strategies aimed at comprehensive system change.
• Encourage open and systematic handling of errors and quality problems to improve care.
• Provide incentives based on quality of care.
• Develop agreements that facilitate care coordination within and across
organizations.

6) Community Resources:

Mobilize community resources to meet needs of patients.

• Encourage patients to participate in effective community programs.
• Form partnerships with community organizations to support and develop interventions that fill gaps in needed services.
• Advocate for policies to improve patient care

Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder
PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lectures

Eat Well, Laugh Often, Love Much

Limiting care to  just MDs and in their own offices presents a serious barrier to pts receiving adequate DSME.  I recently had a pt go through classes and his ins. plan (Mailhandlers Ins.) had this restriction.  He found the DSME so helpful that he continued with the program despite having to pay out of pocket.  It seems to me it would be more cost effective for insurance plans to pay for DSME  by CDE's. Doctors tightly packed schedules do not have adequate time and the wide variance in diabetes knowledge of PCPs can also be an issue.