Diabetes is a critical health issue for our country and for the nation’s Preferred Provider Organizations (PPOs). Diabetes takes an enormous toll on the physical health and quality of life of patients; it is costly for payers and patients, and it is challenging for physicians and other providers to identify and manage.
But research has shown us that diabetes can be successfully managed. When diabetes is controlled, patients experience fewer complications and can lead healthier, more productive lives. This Toolkit is designed specifically for PPO senior staff: medical directors, quality improvement staff and contracting staff. The goal is to help PPO health care leaders understand the diabetes problem and visualize strategies for improving diabetes identification and care. The Toolkit offers resources to assist PPO leaders in making the case for high quality care to their partners and customers in the health care system: payers, providers, and patients.
This Toolkit offers “talking points” about effective diabetes prevention and care management and offers resources to help users find more practical information that they can adopt in their own organizations.
About AAPPO and the ACT on Diabetes Initiative
AAPPO is the leading national association of network-based preferred provider organizations (PPOs) and affiliate organizations. AAPPO’s members represent diverse models of PPOs, including network-only PPOs and “at risk” PPOs that offer a network integrated with an insurance product. AAPPO’s members are world-class provider networks that put care control in the hands of the physician and patient, empowering both and resulting in better care. PPOs provide easy access to quality care provided by the right doctor, providing the right care, at the right time.
In 2007 AAPPO implemented the “ACT on Diabetes” Campaign to help PPOs take Action, Champion better care, and empower patients to Take charge of diabetes. ACT on Diabetes has brought education and information to PPOs, to support them in adopting best practice approaches to diabetes care improvement consistent with their business models.
Our Partnership with DMAA
In 2007 AAPPO forged an alliance with DMAA: The Care Continuum Alliance (DMAA). DMAA is a 200 member organization that convenes stakeholders providing services along the care continuum toward the goal of population health improvement. These care continuum services include strategies such as health and wellness promotion, disease management, and care coordination. DMAA promotes the role of population health improvement in raising the quality of care, improving health outcomes and reducing preventable health care costs for individuals with chronic conditions such as diabetes and those at risk of developing chronic conditions such as diabetes.
This Toolkit was developed in partnership with DMAA: The Care Continuum Alliance.
About the Facts and Figures in this Toolkit
There is a vast amount of information available about diabetes and its complications, and new information is constantly being generated. For this Toolkit we have tried to locate the most up-to-date information about the care and treatment of diabetes. In the documents referenced here, readers will see some differences in data about the prevalence of diabetes and diabetes complications. This is because new research and statistics are generated constantly. The important thing to remember is that diabetes is becoming more common; the cost and complications of diabetes will continue to grow unless all sectors of the health care system – plans, payers, providers, and patients - collaborate to implement effective strategies for delivering high quality care and prevent diabetes.
What is Diabetes and Quality Diabetes Care?
According to the Centers for Disease Control and Prevention (CDC), “Diabetes is a group of diseases marked by high levels of blood glucose resulting from defects in insulin production, insulin action, or both. Diabetes can lead to serious complications and premature death, but people with diabetes can take steps to control the disease and lower the risk of complications.”
Type 1 diabetes occurs in about 5-10% of cases and requires insulin for treatment. Type 2 diabetes is associated with risk factors, some of which can be controlled, such as being overweight or inactive, and some of which cannot, such as a family history or race/ethnicity.
The American Diabetes Association says
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20.8 million children and adults -- 7.0% of the population -- have diabetes.
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14.6 million people are diagnosed with diabetes, and 6.2 million people who have it do not know it.
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54 million people have pre-diabetes, meaning they will get diabetes if they do not change risk factors.
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Type 2 diabetes, although still relatively rare in children, is being diagnosed more frequently in children and adolescents, particularly in American Indians, African Americans, and Hispanic/Latino Americans.
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The prevalence of diabetes is at least 2 to 4 times higher among non-Hispanic Black, Hispanic/Latino American, American Indian, and Asian/Pacific Islander women than among non-Hispanic white women.
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The total estimated cost of diabetes in 2007 is $174 billion, including $116 billion in excess medical expenditures and $58 billion in reduced national productivity.
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Medical costs attributed to diabetes include $27 billion for care to directly treat diabetes, $58 billion to treat the portion of diabetes-related chronic complications that are attributed to diabetes, and $31 billon in excess general medical costs.
Detailed information on diabetes facts is in Tab 3.
Importance and Impact of Diabetes
Diabetes is important because it is costly to everyone:
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Patients suffer when their diabetes is untreated, out of control, or when serious complications occur
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Employers/ purchasers suffer when they pay for ever-more expensive health insurance AND lose the productivity of sick employees
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Providers suffer when they believe the care they offer is not reaching its potential impact to improve health and quality of life outcomes.
Complications of diabetes also have a large impact on health outcomes. Complications such as nerve and eye damage are often the result of damage to tiny blood vessels in organs caused by high levels of glucose in the body. In addition, people with diabetes are at significantly higher risk for developing co-morbid health problems such as heart disease. CDC says:
We know how to prevent most cases of diabetes: by reducing some of the controllable risk factors through lifestyle change. We also know how to treat diabetes to reduce the number of complications. Effective care is a partnership between patients, physicians, and other professionals such as disease management providers, eye care professionals and diabetes educators. Payers contribute through effective benefit design, and PPOs/plans offer coordinating services, effective networks, and information. The Toolkit includes information on standards of care for diabetes, and tools to help physicians and other clinicians to deliver the best care possible.
Role of PPOs in Diabetes Prevention and Treatment Quality
PPOs are involved in delivery of care for 64% of all privately insured Americans. Some PPOs pay for care as the insurer, while others supply the network of physicians and other providers to a self-insured employer or insurance organization. Using the tools and information in this Toolkit, PPOs can reach out to their primary customers – payers, providers, patients or all of the above, with information, tools, and best practices strategies. The Toolkit focuses primarily on outpatient care and management of diabetes.
Our Definitions: A payer is the organization responsible for payment
of health care services. The payer could be a large employer that self insures, state or federal governments, or an insurance company or health plan. Providers are the physicians, ancillary professionals such as optometrists and podiatrists, diabetes educators and other specialists who create a team to deliver, coordinate, and improve care for patients. Patients are always part of the equation, because they have responsibility for their own health and also pay a share of health care costs.
PPOs, regardless of their business model, can engage patients, payers and providers through a variety of options including:
- Selective contracting with high quality providers or increasing patient awareness of quality providers through directory recognition;
- Consulting with payers (employers, plans, insurers) to create benefit strategies that include incentives for patients to seek care and take care of themselves as necessary;
- Partnering with payers to create physician incentives;
- Offering web based information, including health risk assessments and patient education to improve patient care;
- Collaborating with other local organizations for a community-based education, information or quality improvement campaign;
- Offering diabetes disease management directly or in partnership with a vendor; and
- Enhancing web links for consumers with up-to-date diabetes information.
More information and links to examples of PPO activities in this area are on the AAPPO Web site.
Measuring the Impact of Better Diabetes Care
All stakeholders striving to improve diabetes care will want to know if they are having an impact. PPOs can work with these partners to develop a meaningful and accurate evaluation program. For patients, it is important to track progress in meeting health indicators to show successes and encourage participation. A number of the resources identified in this Toolkit offer information for patients on what to monitor and tools, such as flowsheets that patients can use. Physicians and other clinicians may want to evaluate their own care against standards of care for diabetes. They may also look for indicators that show successes and/or improved efficiencies in their practice. Tools such as the National Committee for Quality Assurance’s recognition programs can help physicians to track their effectiveness; efficiency measurements are under development and will be available in the future.
Payers in particular want to under stand the “return on investment (ROI)” for investments in care improvement. Their “investment” in better diabetes care can be through purchase of disease management, offering worksite wellness, promoting information on diabetes care and prevention, or using benefit design to promote patient adherence. PPOs can work with payers and other vendors to identify key metrics. Evaluation will help determine the cost effectiveness and overall impact of a program and will guide adjustments to a program where needed. Evaluations can also give payers, providers, and patients the information needed to make decisions around a plan of care.
An evaluation plan should incorporate clinical, financial, and other measures. These may include health status, satisfaction and risk reduction /behavior change measures. Clinical effectiveness measures may include Hemoglobin A1C testing and results, cholesterol testing and results, smoking cessation assessment and counseling, blood pressure assessment and control, results of eye and kidney testing, vaccination rates, and other indicators. An evaluation program must be designed to evaluate what could be impacted by the intervention. As such, the evaluation plan will be different depending on the intervention and depth of services offered. Payers should know that not all interventions have an immediate return on investment. Many diabetes risk reduction, health and wellness programs may have a longer term financial return on investment but may see short term improvements in risk reduction. Because of this, measures of effectiveness for a diabetes program should include measures that are both long term such as changes in health status and short term such as changes in utilization.
How to Use the Toolkit
This Toolkit is designed to help PPOs make the case to payers, patients and providers about ways that each can help to improve the quality of diabetes care. PPOs are positioned to support payer programs and to partner with a range of organizations to execute patient and provider oriented diabetes improvement activities. AAPPO and DMAA encourage PPO leaders to review the talking points and use the Internet to review the many resources available to support diabetes quality improvement. Then we encourage members to reach out to payers, providers, and patients to talk about diabetes care performance and what each stakeholder can do to improve care and add value to the health care system.
The goal of this Toolkit is to provide PPO senior staff with tools and information to talk effectively with and actively engage payers and providers to reach out to patients with diabetes and those that are at risk for diabetes to help patients maintain or improve their daily health. The fact is, diabetes is costly: to the patients who live with it, to physicians and other diabetes providers looking to deliver the most effective care, and to employers, who pay for health insurance benefit costs and pay the cost of lost productivity.
For payers, the important facts are:
- Diabetes is an increasingly common medical condition – and it is most costly when left untreated or out of control
- Payers have a role in promoting effective approaches (with support from PPO networks, plans, and other vendors) including:
- Education of their employees and health vendors
- Prevention and screening programs
- Worksite programs
- Disease management and other care management approaches
- Creative benefit design
- Resources are available in the public domain, such as the National Diabetes Education Program and from private vendors, to support employers with programs to prevent and help employees more effectively manage diabetes
For providers, the important facts are:
- Standards of care for diabetes are complex, especially when co-morbidities are involved, which is often the case. Standards of care call for management of blood glucose, cholesterol, and monitoring for eye, kidney, cardiovascular, and nerve complications. Physicians can improve the quality of care they provide to both patients with diabetes and those that are at risk by:
- Using reminders and workflow tools to support their office practices
- Supporting patients by offering self efficacy and self management education
- Using other professionals as needed to provide complementary services in the most cost effective and efficient manner for the patient
- Physicians can demonstrate the quality of their services by meeting standards of care for diabetes management and achieving recognition as a high quality provider through ongoing data collection and evaluation
For patients, the important facts are:
- People should understand their risks of diabetes and what they can do to control risks. A risk assessment tool can help individuals understand how behavior can increase or decrease risk of diabetes, and how to adopt exercise, nutrition, and smoke-free habits to improve health.
- Diabetes can be complicated to manage. People who understand the disease and how to manage it have fewer complications and live a healthier life. Patients can take control of their diabetes by:
- Working with their physician and other providers to understand how to prevent diabetes, or to keep it under control
- Knowing what tests and treatments are needed to control diabetes
- Taking advantage of lifestyle changes such as better eating, exercise and stopping smoking
- There are many resources, including web sites and support groups that can help people with diabetes understand how to manage diabetes and learn to live a healthy life with diabetes. Sources of information include the American Diabetes Association, PPOs and health plans, private organizations, professional groups, and the federal government.
Acknowledgements
This Toolkit was developed by the American Association of PPOs in collaboration with DMAA: The Care Continuum Alliance. AAPPO thanks the members of both AAPPO and DMAA who contributed to development of the Toolkit and provided feedback throughout the process.
AAPPO sought to include reference material that is easily available on the web at low or no cost. Other outstanding materials are also available for purchase from proprietary sources. AAPPO expresses deep appreciation for the organizations that sponsored development of the Toolkit.
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Copyright AAPPO April, 2008
