The View from AADE
In August, Close Concerns hopped down to Los Angeles for the annual meeting of the American Association of Diabetes Educators (AADE). There were over 3,000 attendees at this year's conference, most of whom were Certified Diabetes Educators (CDEs). These clinicians are often described as being on the "front line" because they are, in some ways, the closest to the disease. Certainly, CDEs are the healthcare providers who see the most diverse patient populations and who also spend the most time with each patient – sometimes, the most by far! While the AADE meeting is an excellent place for them to network and share information about trends and progress in diabetes therapies, they also took the time to share strong opinions about the importance of education, insurance coverage, and patient self-management.
As we discussed with many educators at this meeting, reimbursement tensions have risen noticeably in the past year. There is little to no coverage for continuous glucose monitoring (CGM) and questions surround coverage for other new drugs like inhaled insulin and the new oral DPP-4 inhibitors (especially for those who want to use it before metformin and other generic drugs) as well. What is even worse for many is the reimbursement situation for diabetes education; for many clinicians, insurance won't even cover the time they need to educate their patients.
While interest in continuous glucose monitoring (CGM) was high for some educators at AADE, there was also an undercurrent of near disdain for the technology, from the educators with many patients unable to afford it and from a few disappointed with early problems with product quality and reliability. Even so, we saw Dr. Francine Kaufman, past president of the American Diabetes Association, and Allison Wick, a noted CDE, give very positive talks to a packed audience about their experiences with CGM. Dr. Kaufman, a highly regarded pediatric endocrinologist, uses CGM off-label for children (to date, Dex Com's STS and Medtronic's 522/722 are not approved for patients under 18). She said that her team learns so much from the data gleaned in pediatric use that treatment changes are extremely common – changes to basal rates, insulin to carb ratios, correction factors, etc. These CGM-guided changes help lower their A1c levels and reduce their glycemic variability. Allison Wick emphasized that CGM promotes more proactive, actionable diabetes self-management. It empowers patients by returning to them the control they lost at diagnosis. She emphasized that, "It is important for patients to feel like they have choices." Don't we know the truth of this! With CGM, a patient can learn over time the nuances of how diet, medication, and activity affect their glucose, and they can then make adjustments to their own diabetes management accordingly. Both clinicians expressed hope that CGM will be reimbursed when the FDA has more data, but our feeling was that many CDEs were quite pessimistic on this issue. In conversation, some expressed the view that it would never be reimbursed at all. To us, the most critical step is undoubtedly obtaining good clinical data, and we certainly hope that the right trials are in the works that will show reductions in A1c's. A1c reductions are still the gold standard for proving efficacy (right or wrong – that's a different column) and for now, they are the minimum needed to convince insurers.
Of course, CGM is not yet the be-all and end-all of diabetes management. The devices continue to have accuracy and reliability issues, though we think that these will improve given time. Another issue is that CDEs do not currently feel they are trained on how to analyze all the data available from continuous records. With the healthcare system they way it is, doctors do not really have time to use so much information in treating their patients, they said. Therefore, it is in fact the educators who have greater hope of being able to sit down with a patient and go over his or her continuous data. The fact that they felt unable to do so points to a larger problem: the unreasonably low reimbursement rates for diabetes education.
There is a national coverage policy for diabetes self-management training (DSMT). The Medicare DSMT benefit became effective in 2001, but numerous limitations to this program exist, as Peggy Bourgeois reported in a Reimbursement Update session at AADE. First, education is only covered for patients who have already been diagnosed with diabetes. This may seem natural at first glance, but there are many patients who are not yet diagnosed but could benefit from education: those with pre-diabetes, of course. What is important is that with the proper education, diagnosis could potentially be prevented entirely in these patients. Second, even for patients with diabetes, Medicare covers only ten hours of training within a 12-month period, and within those 12 months nine hours must be in a group setting and only one hour may be one-on-one! Peggy Bourgeois recommended to her audience members that if they saw a patient individually for a second hour, they should charge the lower group rate or they won't be paid at all. Third, an educator may only bill in exact 30-minute increments – nothing in between a half hour and an hour – which means there is a lot of rounding down. Astonishingly, all of these conditions belong to the best case scenario. The sobering reality is that over 50% of state Medicaid programs do not even cover DSMT at all. We came out of this talk with a strong impression that with more support, educators could be doing a lot more good for patients, but they are not even getting paid for what they are already doing. This is disgraceful, in our view.
The greater anger toward payers that we noticed at this year's AADE comes at least in part out of a recent clinician emphasis on prevention. We heard many CDEs conclude that prevention was the most important learning in diabetes this year. No doubt these healthcare providers feel that payers need to get with the new program. The annual cost of diabetes (direct and indirect) as measured in 2002 was a staggering $132 billion, most of which went to treatment for complications. Providers often treat patients for acute complications without addressing the underlying disease optimally, or – some would say – at all.
The AADE7 was much discussed at this conference. This chronic care model outlines seven behaviors that serve patients well: eating healthily, being active, monitoring, taking medications, problem solving, healthy coping, and reducing risk. Although these may sound straightforward, the AADE has worked hard to help patients take responsibility for these behaviors. We felt that this year's meeting really hit home on the important point that when treatment shifts from a focus on acute complications to a focus on preventative self-management, we will all be better off. We encourage all patients to ask their healthcare providers what they can do in order to more actively self-manage their condition. We also thank educators everywhere for all the work they do in helping us (patients and families alike) overcome the many challenges of diabetes.
NOTE: The information is not intended to be a replacement or substitute for consultation with a qualified medical professional or for professional medical advice related to diabetes or another medical condition. Please contact your physician or medical professional with any questions and concerns about your medical condition.
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