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Implications of U.S. Health Care Reform on the Care and Prevention of Diabetes
In a symposium chaired by Ronald Ackermann, MD, MPH on Friday, June 25, the first afternoon of the American Diabetes Association 70th Annual Scientific Sessions, a panel of experts discussed the potential impact of U.S. health care reform for patients with diabetes. The focus of this program was the recently enacted U.S. health care reform bill, the Patient Protection and Affordable Care Act. In the course of the symposium, the expert speakers
• Outlined the need for improved access to evidence-based health care for patients with diabetes
• Summarized anticipated gains and pitfalls for patients with diabetes under the recent health care reform
• Described the role of communities in improving health care outcomes
• Provided examples of community-based programs that may provide efficient and cost-effective means to achieve health care reform goals.
A webcast of the symposium is available at: http://professional.diabetes.org/WebcastList.aspx?ses=2301&idc=140.
Dr Ackermann introduced the program by highlighting data from the National Health and Nutrition Examination Survey (NHANES) which indicate that > 20% of individuals with prediabetes (impaired glucose tolerance or impaired fasting glucose), undiagnosed diabetes, and diagnosed diabetes have no insurance coverage. He noted that more individuals in the groups with prediabetes or undiagnosed diabetes were not covered. In addition, significant numbers of people in all 3 groups do not receive optimal care. Furthermore, Shereen Arent, JD, American Diabetes Association Executive Vice President for Government Affairs and Advocacy, noted that 25% of households with a diabetes patient pay >10% of their income for health care-related expenses, and in 8% of such households, > 20% of household income is used for health care.
Dr Arent noted that while implementation of recent U.S. health care reform has begun, the bill will not be fully implemented until 2014. She highlighted the following anticipated gains that are particularly relevant to patients with diabetes.
• The health care reform bill includes provisions to prevent discrimination based on a diagnosis of diabetes.
o It will be unlawful to deny health care to a person specifically because they have diabetes.
o Patients with a diagnosis of diabetes cannot be dropped from health care coverage.
• Multiple coverage options are specified, including government and private sources. Programs which pool large numbers of people, such as exchanges, interstate compacts, and nationwide plans, are anticipated to increase affordable options for individuals and small groups.
• The health care reform bill specifies categories of essential benefits that should be included in health care plans, for example, ambulatory patient services, hospitalization, patient drugs, laboratory services, and preventive and wellness services and chronic disease management. Although these may not be covered by every plan, they should be covered by a large number of plans.
• Stipulations are included to improve health care availability and affordability for patients with diabetes, such as:
o No premium discrimination for individuals with diabetes
o Workplace wellness provisions
o No annual or lifetime limits on health care benefits
o Deductible and out-of-pocket limits
o Free preventive services
o Medicaid expansion to include households with income up to 133% of the federal poverty limit – This condition increases coverage to include16 million individuals who are currently not receiving benefits. This will encompass young adults transitioning from their parents’ insurance plans and those who are near the poverty limit.
o Medicare benefits that limit on out-of-pocket costs and include free annual wellness and personalized prevention plans and prevention services
• Primary prevention initiatives are specified, including items such as establishment of a $15 billion Prevention and Wellness Trust Fund and menu labeling requirements. At this time, the bill is still under regulatory review to determine what groups and programs will be eligible for funding from the Prevention and Wellness Trust Fund.
• Diabetes-specific items are also included, such as funding for a National Diabetes Prevention Program
Dr Arent repeatedly cautioned that continued efforts will be necessary to ensure the best possible benefits are provided for patients with diabetes. For example, the implemented essential benefits package will need to include diabetes-specific screening and services, prescriptions, and durable medical equipment. Workplace wellness provisions should include evidence-based programs with demonstrated efficacy so individuals are not penalized or charged extra for failing to meet frivolous goals. Also, triggers for free preventive services should include appropriate diabetes-specific benchmarks, such as obesity and gestational diabetes in addition to hypertension. Dr Arent also suggested prudence should be exercised regarding “grandfathered” plans, which may not be subject to the new legislation.
Stephen H. Woolf, MD, MPH, continued with a discussion of the role of primary care and the community in the prevention of chronic disease in the era of health reform. He began by stating the spending on health care is projected to increase to well over 20% in the years to come, posing an economic crisis. Chronic disease contributes significantly to these costs. Although current medical practice emphasizes the use of medical treatments to achieve immediate benefits in treating chronic disease, a long-term view is necessary. Much chronic disease might be prevented with healthier lifestyles, including better diets, more exercise, eliminating tobacco use, and limiting alcohol intake. Although these preventive behaviors can provide substantial benefits, it takes longer to realize the return compared with medical treatments.
Because influences on health behaviors come from many sources, including social networks, it is important to encourage schools, community organizations, government regulatory agencies, public services [such as restaurants], health insurance companies, etc. to recognize that this is not the problem of clinicians and patients alone and to become active participants in solving the problem. Dr Woolf provided examples of several successful efforts that paired patients at risk for diabetes with community programs, such as Weight Watchers or the YMCA, to receive diabetes education and lifestyle intervention. These efforts are similar to approaches used by the Diabetes Prevention Program (DPP), but applied at the community level. In conclusion and to illustrate the diversity of approaches that can impact health outcomes, Dr Woolf stated that completion of high school education is associated with lower mortality, so perhaps the American Diabetes Association should also be more active in education reform.
Deneen Vojta, MD, with UnitedHealth Group, a Minnesota-based health insurance company, addressed the evolving role of health insurance companies in the era of health care reform. At the beginning of her presentation, Dr Vojta noted that a mandate, a large pool of individuals, and money are needed for health care reform. The question remains – how can costs be controlled? Health insurance companies have a vested interest in this question and in order to keep health care costs down, they may need to re-evaluate and revise their role. Traditionally, health insurance companies have paid for sick care and acted in a transactional capacity to process claims and aggregate risks. Health care reform provides opportunities for health insurance companies to pay for health care and transform the health care system by providing support to health care providers and patients and by assuming a greater role in disease prevention.
Dr Vojta continued with a description of a program to prevent diabetes initiated on June 1, 2010 by the Diabetes Prevention and Control Alliance (DPCA), comprised of UnitedHealth Group, the Centers for Disease Control and Prevention (CDC), and the YMCA. The program is an effort to replicate results of the DPP in a large scale program. It will initially launch in 6 markets over 4 states, but will roll out nationally over 2010-2012 (http://unitedhealthgroup.mondosearch.com/cgi-bin/MsmGo.exe?grab_id=0&EXTRA_ARG=&CFGNAME=MssFind.cfg&host_id=42&page_id=386&query=diabetes&hiword=diabetes%20DIABETIC%20). The DPP relied on individual coaches, which would be too expensive for a large-scale program. Accordingly, the DPCA adopted a group model. Rather than taking 3-5 minutes during an office visit to explain the importance of exercise, physicians will take 30 seconds to 1 minute to refer patients to the YMCA. Available technologies will be used to identify, engage, and track patient adherence to the program. Similarly, the DPCA is initiating a Diabetes Control Program in partnership with Walgreen’s pharmacies. The DPCA programs are connected to a health care home such that physicians provide referrals and get information back. The programs also provide convenience, through swipe card payment at the point of service, and, as preventive care services, there should be no cost to participants under the new health care reforms. Next steps include development of partnerships with other health care providers and retail pharmacies; expansion to more patients, including children, Medicare, Medicaid, and employer health plans; and efforts to benchmark and report progress.