MCO changes for diabetes care: Don’t miss the boat

Comprehensive coverage is the wave of the future

Right now, your managed care organization (MCO) is probably missing out on the quality improvement opportunity of a lifetime, many experts say. Although most MCOs provide some disease management services for their members with diabetes, recent data suggest that few have gone far enough to maximize savings and patient outcomes.

A recent Gallup survey of benefit managers from 252 large employers reveals that of the health plans available to employees, three-quarters do not cover patient education classes for all members with diabetes, about half don’t cover lab tests, and 38% don’t cover blood glucose meters. (For more survey results, see charts, pp. 31 and 33.)

This situation exists despite the fact that diabetes affects an estimated 15.7 million Americans, is the country’s fourth leading cause of death, and accounts for one in seven health care dollars spent annually in the United States, according to the Alexandria, VA-based American Diabetes Association (ADA). And as the population ages and grows increasingly obese, those numbers are only expected to increase, says ADA president Mayer Davidson, MD. Other factors include the sedentary lifestyle of many Americans and the growing population of ethnic groups at higher risk for diabetes, especially Latin Americans, Davidson adds.

Yet, even given these statistics, the state of diabetes management in the United States remains poor, says Richard Kahn, PhD, chief scientific and medical officer at the ADA. "Nationally, there isn’t anything in diabetes care that’s up to par from the eye exam, where the [compliance] rate is 40%, to the measurement of urinary protein, where the rate is about 20%, to foot exams, which aren’t being done, to virtually anything in diabetes."

Davidson attributes the poor state of diabetes management to the problem of physicians having neither the time nor the resources to properly educate patients about their condition. And often physicians themselves lack complete knowledge of this complicated disease. Additionally, patients often don’t consider diabetes to be a very serious condition.

"The thing is, diabetes doesn’t hurt," Davidson says. "That means there’s little motivation on the surface for patients to do anything about it because they feel fine for the most part. They don’t complain to their doctors, and therefore, the doctors don’t have to respond. They don’t push it because they’re busy enough doing other things."

Disease overlooked, not given proper focus

David Detmers, marketing and communications manager for Milpitas, CA-based LifeScan, a leading maker of blood glucose meters and the company that commissioned the Gallup survey, doesn’t believe that health plans knowingly discount diabetes.

"I don’t think there’s any covert plan to ignore this," he says. "But there’s a lot of competition for attention and focus, and diabetes really hasn’t gotten its fair share."

In fact, most health plans do cover basic disease management services and tools for insulin-dependent members. But Type I diabetes accounts for only 5% to 10% of all cases of diabetes, according to the Atlanta-based Centers for Disease Control and Prevention.

"In some respects, people who require insulin to live are in better control because they don’t have a choice," Detmers says. "But many Type II diabetics eventually move on to insulin. They are the ones who have this progressive onset of complications — the nerve damage, the vision loss, the dialysis, the amputations, and all of this microvascular damage."

It’s widely accepted that education and monitoring of non-insulin-dependent members with diabetes can serve to reduce complications over the long haul, Davidson agrees. The problem is that managed care isn’t yet a long-haul industry. Most members stay with their health plan for less than two years, says John C. McDonald, RN, MS, CPHQ, vice president of clinical services at Physicians Community Health in Brentwood, TN. "There are some short-term gains, but most of the gains are long term, with [prevention of] things like comorbidities, vascular disease, amputations, and blindness — things MCOs aren’t going to see a quick return on."

Davidson adds that the upfront cost of implementing diabetes management has also discouraged some MCOs, which "are so competitive with each other for next year’s premium that they don’t want to spend the resources for five or six years down the road because the patients may not be there in five or six years."

Detmers argues that this attitude ignores an important point. "They focus on the fact that patients are churning out of their plan but don’t acknowledge that patients are also churning in from other plans. It’s fundamentally in everyone’s best interest to do what they can to forestall the complications, improve the quality of life for these folks, and save some money while doing it."

Detmers adds that short-term cost savings from diabetes management are often underestimated. He notes, for example, that it doesn’t take many years for uncontrolled diabetes to have a negative impact on vision. Management can also reduce hospitalizations in the short term resulting from hyper- or hypoglycemia. "Even in the short term, a day or so in the hospital and all the associated costs far outweigh the costs of paying for testing supplies and patient education," he says.

With its comprehensive NetCare diabetes management carve-in, the Nashville-based Diabetes Treatment Centers of America claim to have reduced hospital admissions for diabetes by 83% and total health care costs by 26% within six months of implementation. (See related story, p. 32.)

Davidson contends that patient turnover will become less of an issue in the future as managed care organizations merge. "There is some hope for a change of heart in that. Because large MCOs are buying up smaller ones, they’re expecting to have their patients longer," he says. "And if there are only three or four large ones left, then it doesn’t matter if the patients drop out because they’re going to be picking up the same patients from other plans." Capitation is another driving factor forcing MCOs, including physician-driven independent practice associations, to consider a more comprehensive approach to diabetes management, McDonald adds.

A third influencing factor is recent legislative action with regard to the care of diabetes. Twenty-three states have already passed laws requiring health plans to provide such tools as patient education and blood glucose meters to all members with diabetes, whether they’re insulin-dependent. Eighteen other states are considering similar legislation, according to the ADA. In addition, beginning July 1, 1998, Medicare will begin covering blood glucose meters, test strips, and diabetes education for all patients with diabetes. "And if the U.S. government is going to provide coverage for supplies and education, it becomes much more difficult for private insurers to refuse them," Detmers says.

As new requirements and incentives slide into place, however, the question becomes whether MCOs will take the opportunity to embrace comprehensive diabetes management or simply obey the letter of whatever laws arise.

"A lot of the resistance is from individuals who are used to operating from the traditional model of how health care is delivered," says Tom Conant, director of behavioral technology at Wayne, PA-based Covalent Research Alliance, which performs outcomes studies and clinical trials research for MCOs and pharmaceutical companies. The company has teamed with Indianapolis-based Eli Lilly and Company to market an interactive self-care program for diabetes, to be released by March 1998. "Things are flip-flopping where now prevention and maintenance are becoming an integral part of how we deliver health care and how we think about delivering health care," he says. "But there’s a lot of re-education that’s going to have to take place. You’ve got groups who are clinging on to what they have and what they know vs. groups who’ve accepted reality and are looking ahead and saying ‘OK, things are going to be different as far as how health care services are structured.’"

[For more information about diabetes management, contact: John C. McDonald, RN, MS, CPHQ, Vice President of Clinical Services, Physicians Community Health, LLC, Two Brentwood Commons, 750 Old Hickory Blvd., Suite 275, Brentwood, TN 37027. Telephone: (615) 373-7315. Tom Conant, Director of Behavioral Technology, Covalent Research Alliance, 1275 Drummers Lane, Suite 100, Wayne, PA 19087. Telephone: (610) 975-9533. David Detmers, Manager, Marketing and Communications, LifeScan, 1000 Gibralter Dr., Milpitas, CA 95035. Telephone: (408) 942-5955. Mayer Davidson, MD, President; Richard Kahn, PhD, Chief Scientific and Medical Officer, American Diabetes Association, 1660 Duke St., Alexandria, VA 22314. Telephone: (703) 299-2065.]