Diabetes and accountable care: A patient-centered focus

A key component of health care reform in the United States is the creation and implementation of health care delivery models and payment methods such as accountable care organizations. These organizations are designed to improve health outcomes and reduce costs of care.

Poor health outcomes and rising expenditures can be partially attributed to the increasing prevalence of chronic diseases, such as diabetes. In 2010, the total direct cost of diabetes care alone was estimated to be $116 billion, with an additional $58 billion for indirect costs, including disability, work loss and premature mortality.

Diabetes care is often fragmented, with patients receiving some care from primary care physicians and other care from specialists such as endocrinologists, nutritionists and diabetes educators — often with little coordination among care providers. Providers tend to have little financial incentive to ensure that patients receive quality, comprehensive care.

Accountable providers

Accountable care organizations (ACOs) are networks of physicians, hospitals and health care organizations that agree to be accountable for quality, cost and overall care of an assigned population, as well as share in cost savings that may be obtained from this integration of care.

Donna Rice

CMS is preparing to launch an ACO shared savings program as a means to improve the quality of care for Medicare beneficiaries and reduce unnecessary costs. ACOs that participate in the CMS ACO shared savings program and meet specified quality performance standards will be eligible to receive a share of any savings if the actual per capita expenditures of their assigned Medicare beneficiaries are a sufficient percentage below their specified benchmark amount.

It is apparent that we must find ways to reduce the prevalence of chronic disease and its related complications. There are many questions surrounding ACOs, such as how they should be organized, reimbursed for care and evaluated on quality, as well as how financial savings among partners should be shared. Although some believe that organizing providers with the promise of financial incentives for improving quality will result in improved patient care, an important part of the equation has been left out — the patient. We believe health outcomes will not improve and health care spending will not decrease unless providers become accountable for engaging patients in health promotion, disease prevention and management so that patients will become producers of health rather than consumers of health care.

Stakeholders in the US health care reform movement have agreed that health care transformation will require “improving population health, engaging patients in making decisions, and managing their care, improving safety and care coordination,” according to an article by Fisher and colleagues in the Journal of the American Medical Association.

Accountable care strategy

The CMS ACO shared savings program could lead to improvement in cost-effective health care delivery, but little emphasis has been placed on formally engaging the patient in the production of health to reduce the consumption of health care services.

Neil Fleming

The Baylor Diabetes Health and Wellness Institute (DHWI) is a new model of care that involves patients in the treatment and prevention of their diabetes by combining clinical care with disease management, including lifestyle interventions that target the unhealthy behaviors that increase the risk for diabetes and the development of diabetes-related complications. The DHWI is a joint partnership between the Baylor Health Care System and the Parks and Recreation Department of Dallas. It is open to the community.

Members engage in education and exercise programs that teach them how to develop and maintain healthy lifestyles. DHWI programs teach skills related to the American Association of Diabetes Educators 7 Self-Care Behaviors: healthy eating; being active; monitoring; taking medication; problem-solving; reducing risks; and healthy coping. Each participating member has an assigned diabetes educator to accompany him or her along the journey toward good health. A multidisciplinary team provides care within the DHWI and works in concert with lay health care workers and community partners to create a coordinated approach to wellness for each member.

We believe that this approach will lead to reduced illness episodes with the financial benefit of fewer ED visits and hospitalizations, as preliminary reports indicate.

The DHWI is one example of an accountable care strategy that puts the patient at the center of care delivery and engages a variety of health and wellness experts in the development of individualized, comprehensive care plans to prevent and mitigate the effects of diabetes-related complications. A patient database allows the DHWI to track and evaluate patient outcomes, and all DHWI staff is held accountable for improving patient outcomes. These strategies should improve the overall quality of care delivered and reduce patients’ need for and consumption of clinical care, as well as represent an important shift from the fee-for-service model to overall patient management, with the goal of achieving optimal cost-effectiveness, given finite resources.

Engaging the patient

This nontraditional approach to care proactively seeks to engage the patient in all aspects of care and empowers the patient to make lifestyle changes that improve health. The model has the potential to reduce health care spending, rather than simply shifting risk that is primarily financial from the existing reimbursement system to ACOs.

Although the financial incentives associated with participation in the CMS ACO shared savings program may drive physicians, hospitals and health care organizations to find innovative ways to deliver care that improves health outcomes and reduces costs, these models will not be effective unless they engage the patient. Providers must give patients the resources needed to manage their own care and empower them to engage in health-promoting activities. Effective disease management will only be achieved by engaging a multispecialty team of health care providers who can treat disease and improve health behaviors.

This team and the patient must all be accountable for improving health outcomes and producing better health. Health care reform must include structures that provide incentives for better patient health created by health care providers and patients themselves.

Donna Rice, MBA, RN, CDE, is president of the Baylor Diabetes Health and Wellness Institute and is a member of the Endocrine Today Editorial Board. William L. Roberts, MHA, CPA, is president of HealthTexas Provider Network and senior vice president of Baylor Health Care System. Ashley Collinsworth, MPH, and Neil Fleming, PhD, are both from the Institute for Health Care Research and Improvement at Baylor Health Care System.

For more information:

• American Association of Diabetes Educators. AADE 7 Self-Care Behaviors. 2011. Available at: www.diabeteseducator.org/professionalresources/AADE7. Accessed March 25, 2011.
• CDC. National diabetes fact sheet: National estimates and general information on diabetes and prediabetes in the United States; 2011. Available at: www.cdc.gov/diabetes/pubs/factsheet11.htm. Accessed March 25, 2011.
• CMS. Medicare Accountable Care Organizations Shared Savings Program – New Section 1899 of Title XVIII Preliminary Questions & Answers; 2010. Access the PDF file here. Accessed March 25, 2011.
• Fisher ES. JAMA. 2010;304:1715-1716.

Disclosures: The authors are all employed at Baylor Health Care System.