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Facing today’s challenges in diabetes education
Access to care is one problem facing diabetes education; solutions are out there, according to some educators.
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Each year the number of Americans diagnosed with diabetes increases; however, some diabetes educators are struggling with the challenge of sustaining their own businesses, faced with the reality that hospitals are cutting back or eliminating their diabetes education programs. Approximately 5% of ADA-recognized programs closed in 2006, according to an American Association of Diabetes Educators Fact Sheet.
Hospitals state that the diabetes education programs can be costly and that fewer patients are interested. Diabetes educators argue that patients may be unaware of the availability of these beneficial programs and that there are ways around the cost factor. Furthermore, diabetes educators can provide patients with the proper guidance, education and diabetes self management tools from the start, which may ultimately help to reduce the number of in-hospital visits each year due to diabetes-associated health complications.
“Diabetes is an ongoing disease. Life changes, treatment changes and management changes. Patients should be able to receive ongoing education as it is needed,” said Virginia Zamudio Lange, RN, MSN, CDE,a past president of the American Association of Diabetes Educators.
“Diabetes costs a lot of money and diabetes educators are one of the solutions to this diabetes problem. We provide patients with the tools and solutions to improve their lives. However, educators themselves are facing challenges that may be preventing them from providing services,” Amparo Gonzalez, RN, BSN, CDE, president of the AADE, told Endocrine Today. Such challenges include financial pressures, reimbursement issues, poor referrals from physicians, decreased hours, issues with billing for diabetes self-management training and medical nutrition therapy, and a need for more educators.
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Endocrine Today interviewed several diabetes educators about a few of these pressures facing diabetes education. Importantly, the professionals interviewed highlighted their efforts and ideas for improving the present and future of diabetes education.
Gaps in care
“The discrepancies in the U.S. health care system have been identified in numerous studies and articles over the years, and yet it seems that the gaps in quality care are widening as the number of people with diabetes increases,” Gonzalez wrote in an article published in a 2008 issue of The Diabetes Educator.
According to Healthy People 2010, a governmental framework for national health care improvements, 45% of people with diabetes received formal diabetes education in 1998. As a testament to the efficacy of diabetes education, the 2010 objective is to increase this figure to 60%. Research backs up the notion that these education programs are effective; numerous published studies have demonstrated that diabetes self-management training leads to reductions in health care costs and hospitalizations and decreases health care utilization.
For example, Ed Wagner, MD, and colleagues reported in a 2001 study published in JAMA that a health plan that covered diabetes education saved nearly $8 in health-related costs for patients with diabetes for every $1 invested in diabetes education. They also reported a sustained reduction in HbA1c levels with regular self-management training.
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Also in 2001, Susan L. Norris, MD, and colleagues conducted a review of 72 studies to determine the effectiveness of self-management training in patients with type 2 diabetes. “Collaborative interventions focusing on knowledge tend to demonstrate positive effects on glycemic control in the short-term and mixed results with follow-up of <1 year. Both individual and group lifestyle interventions had positive effects on diet and self-care behaviors. It is notable that skills teaching were effective in both group and individual settings,” they wrote in Diabetes Care.
Yet despite the efficacy of formal diabetes education programs, diabetes educators remain underutilized, according to Donna Rice, MBA, RN, BSN, CDE, immediate past president of the AADE and an Endocrine Today Editorial Board member. Access to care is one of the biggest issues facing diabetes educators today, according to Rice, who is an educator at Botsford Center for Lifestyle Management, Novi, Mich.
“We need to increase awareness on the benefits of diabetes education because it is a benefit [patients] have access to that they do not always know about,” she said.
There are over 15,000 certified diabetes educators in the United States and another estimated 15,000 diabetes educators in practice, according to the AADE. For every certified diabetes educator, there are an estimated 1,600 patients in need of services. Data from an AADE National Practice Survey from 2005 and 2006 showed that 63% of diabetes educators reported seeing fewer than 500 patients per year, or two patient visits per day, and 42% reported seeing more than 1,001 patients per year, or four patients per day, according to the survey results (see chart).
“Even though you would think patients are knocking down our doors and waiting in line for education, the fact is, they’re not,” said Mary Austin, MA, RD, CDE, owner and president of The Austin Group, LLC, in Shelby Township, Mich and an Endocrine Today Editorial Board member.
Barriers
Austin suggested several barriers that may be contributing to the decline in patients receiving diabetes education. One is that patients are required to receive a referral by physicians in order to obtain the service. Patients may not be receiving referrals to diabetes educators, and without that referral the service may or may not be a covered benefit. Also, the patient’s knowledge of diabetes education and their geographical proximity to a diabetes education care center can also be another limitation to receiving care.
“In order to really make money in diabetes education we have to have volume, just like any other business. A diabetes education program without volume and a packed schedule will not be able to actually make money,” added Austin, who reported the AADE National Practice Survey results from 2006 with Malinda Peeples, RN, MS, CDE, in The Diabetes Educator in 2007.
The Balanced Budget Act of 1997 provided coverage for diabetes self-management training. It expanded the types of providers recognized to bill for diabetes education, which was previously only billable through hospital departments. The Centers for Medicare and Medicaid Services issued a rule to implement expanded coverage of outpatient diabetes self-management training, authorized by this act, and health plans soon followed suit.
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Photo by Matt Gragg |
One challenge in this arena is that Medicare will only cover diabetes education if it is ordered by the patients’ physician and included in the comprehensive plan of care. Physicians do not universally send all patients to diabetes self-management training and may not understand the many benefits of education, according to Zamudio Lange, who is now an independent diabetes consultant. Not all insurance carriers cover diabetes self management education. Often, when a patient is referred, insurance may cover only a few hours of education per year. Medicare, for example, covers one 10-hour initial training within a rolling 12-month period and two hours of education every year after. However, many diabetes educators Endocrine Today interviewed said that is not enough.
Certified diabetes educators, unlike nurse practitioners or nurse midwives, for example, are not recognized as care providers by Medicare and cannot bill for services directly, but must bill through a hospital or physician office. However, dietitians are recognized providers and are allowed to bill CMS for medical nutrition therapy services.
“If certified diabetes educators could bill directly, there would be tens of thousands more educators that could serve patients who are not currently receiving education. This would open up access and help me and my colleagues have a more viable livelihood,” Zamudio Lange told Endocrine Today.
Diabetes educators use HCPCS G codes to bill Medicare for diabetes self-management training: G0108 and G0109. In 2001, the participating physician allowance for G0108 under the Medicare fee schedule was $63.13 and the corresponding allowance for G0109 was $37.11. A group of just three Medicare beneficiaries would generate $111.33 for 30 minutes of training, according to an article written by Kent J. Moore, manager of health care financing and delivery systems for the American Academy of Family Physicians.
According to Gonzalez, about a third of patients with diabetes are covered by Medicare, one-third are covered by private insurance and one-third of patients do not have any insurance. However, there are services and programs for patients without insurance. In 2005, 26% of diabetes education programs were reimbursed by Medicare and 19% reimbursed by managed care, according to findings from the AADE National Practice Survey. Results from the 2007 National Practice Survey appear to be reporting similar trends.
“Let’s be realistic. Large centers that are doing a substantial amount of billing should be viable. But the majority of education programs are not large programs in hospitals; most are outpatient clinics or private, totally at the mercy of referrals if the educators are counting only the money made from actual education,” Austin said.
In 2005, the Centers for Medicare and Medicaid Services reimbursed $4.8 million for diabetes self-management training costs, according to AADE statistics. About 42% of managers reported that their program operated at a loss, and 14% reported their program operated at a profit, according to the survey findings.
“In an ideal world, as diabetes educators we could tailor our programs to the needs of the patient, and the reimbursement fees for the services provided would be enough to cover our costs and allow us to have a good financial model in diabetes education,” Gonzalez told Endocrine Today.
Addressing these challenges
 Mary M. Austin |
What are some possible solutions to the issues outlined above? Many diabetes educators are seeking ways to capitalize on new directions and opportunities, face these challenges, and improve the care they provide.
Moving diabetes education into nontraditional settings may offer one solution. Education “must move away from the hospitals and out into communities where the people with diabetes play and work,” Gonzalez suggested during the AADE 35th Annual Meeting in August. These settings may include retail clinics in large stores such as Wal-Mart and Target, and community- and employee-based wellness centers. Different settings can open up new opportunities for educators to connect with patients and help create new educator job opportunities, according to Gonzalez.
“Expand the wall and move your program out. Diabetes is growing, your business should be growing, too,” said Rice. That is how she overcame the barriers at her diabetes program, where educators are right in the physician’s offices where the patients are.
Nearly all of the diabetes educators Endocrine Today interviewed said an improved partnership between physicians and educators is essential for diabetes education to be sustained.
“It would be great if diabetes educators and endocrinologists could really join forces and work closer. There are many opportunities to take it to a higher level,” Gonzalez said.
The future of diabetes education must also include more training and recruitment of recent graduates to enter the field. Many diabetes educators say they just fell into diabetes education. The AADE is currently developing a more concrete career path into diabetes education. “We know the epidemic is out there, but we need to focus on moving more people into education,” Rice said.
The AADE supports diabetes educators and the organization is developing several initiatives, such as primary care practice programs to deliver diabetes self-management training in a variety of settings, multi-level career path guidelines and an Entrepreneurial Training Toolbox to help members develop their own businesses.
As for the financial aspects that may hinder diabetes education programs, Gonzalez said, “The AADE is fully aware and concerned with the revenue model, and we are having conversations with federal agencies to address the issue, and they are listening. Solutions will not come overnight, but we are definitely moving in the right direction in being heard about this issue.”
The AADE is working to pass legislation that would allow Medicare to recognize certified diabetes educators as providers. In addition, CMS’s 9th Statement of Work will focus on diabetes self-management.
“In other words, efforts are underway to help improve this current situation,” Gonzalez said.
As it stands, however, “diabetes education as we know it today will need to change if it is to serve the ever-growing number of people with diabetes in the United States,” Austin said. – by Katie Kalvaitis
Is diabetes education truly profitable?
Patients must take responsibility for their own health: Perspective from Endocrine Today’s Chief Medical Editor
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The current crisis in diabetes education reveals a fatal flaw in the present system of employer-sponsored health care plans that cannot be overcome by transforming more insured out of uninsured patients. The problem is that patients see themselves as having little or no responsibility for their own health care or its outcomes. Consequently, if it is not covered by their insurance they do not believe it necessary for themselves to arrange this education. This is an impossible situation to continue, as the demand will only escalate for more and more services that must be free or minimally charged to the patient; otherwise they go unfulfilled.
When patients take more responsibility for themselves and arrange for necessary services, out of pocket if necessary, then there will be more education. Health plans with more educational benefits cost more than plans without such benefits. Most commonly, patients select from a menu of health care plans the least expensive rather than the most beneficial plans. Patients must be willing to pay for such beneficial plans and benefits; otherwise they will disappear from the marketplace, no matter how necessary we believe these services to be. Government funding of health care only worsens this already intolerable situation since it amplifies the concept that someone other than the patient is responsible for funding the patient’s health care. This is a concept that, like the bread and circuses of Ancient Rome, undermines and weakens rather than strengthens the structure of its society.
– Alan J. Garber, MD, PhD
Professor in the Departments of Medicine, Biochemistry and Molecular Biology,
and Cellular & Molecular Biology at Baylor College of Medicine, Houston,
and Chief Medical Editor of Endocrine Today
For more information:
- Zamudio American Diabetes Association. Third-party reimbursement for diabetes care, self-management education and supplies. Diabetes Care. 2003;26:143-144.
- Bartlett E. Historical glimpses of patient education in the United States. Patient Educ Counsel. 1986:8:135-149.
- Bourgeois P. Insurance: what our patients need to know. Diabetes Spectrum. 2005;18:62-64.
- Gonzalez A. Diabetes education for all! Diabetes Educ. 2008;34:373.
- Moore KJ. Billing Medicare for diabetes self-management training. Fam Pract Manag. 2001;www.aafp.org/fpm/20010400/14bill.html.
- Norris SL, Engelgau MM and Narayan KMV. Effectiveness of self-management training in type 2 diabetes. Diabetes Care. 2001;24:561-587.
- Peeples M and Austin MM. Toward describing practice: The AADE National Diabetes Education Practice Survey: diabetes education in the United States – who, what, where and how. Diabetes Educ. 2007;33:424-433.
- Wagner EH, Sandhu N, Newton KM, et al. Effect of improved glycemic control on health care costs and utilization. JAMA. 2001;285:182-189.