Shortcomings in public and private insurance coverage of state-of-the-art diabetes self-management

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1 Shortcomings in public and private insurance coverage of state-of-the-art diabetes self-management Delesha M. Carpenter, PhD, MSPH Edwin B. Fisher, PhD April 10, 2010

2 Objective To characterize public and private insurance coverage for Diabetes Self-Management: Education Support

3 Diabetes Self-Management Education The ongoing process of facilitating the knowledge, skill, and ability necessary for diabetes self-care. Affects quality of life and clinical indicators 60-70% have not received DSM Education Funnell et al, 2010; Austin, 2006

4 Diabetes Self-Management Support Activities to assist the individual with diabetes to implement and sustain the ongoing behaviors needed to manage their illness. Case management Funnell et al, 2010

5 State Laws In 2009, 46 states had laws requiring private insurance to offer coverage for individuals with diabetes Includes DSM Education Great variability in specificity of laws ms/tabid/14504/default.aspx

6 Example Law Every policy which provides medical coverage that includes coverage for physician services in a physician's office and every policy which provides major medical or similar comprehensive-type coverage shall include coverage for the following coverage for diabetes self-management education to ensure that persons with diabetes are educated as to the proper self-management and treatment of their diabetic condition, including information on proper diets. Such coverage for self-management education and education relating to diet shall be limited to visits medically necessary upon the diagnosis of diabetes, where a physician diagnoses a significant change in the patient's symptoms or conditions which necessitate changes in a patient's self-management, or where reeducation or refresher education is necessary. Such education may be provided by the physician or other licensed health care provider legally authorized to prescribe under title eight of the education law, or their staff, as part of an office visit for diabetes diagnosis or treatment, or by a certified diabetes nurse educator, certified nutritionist, certified dietitian or registered dietitian upon the referral of a physician or other licensed health care provider legally authorized to prescribe under title eight of the education law. Education provided by the certified diabetes nurse educator, certified nutritionist, certified dietitian or registered dietitian may be limited to group settings wherever practicable. Coverage for self-management education and education relating to diet shall also include home visits when medically necessary.

7 Another Example Each insurer that issues or renews any individual policy, plan, or contract of accident or health insurance providing benefits for medical or hospital expenses, shall provide to certificate holders of such insurance, who are residents of this state, coverage for medically appropriate and necessary outpatient self-management training and educational services, pursuant to a written order of a primary care physician or practitioner, including but not limited to medical nutrition therapy for the treatment of diabetes, provided by a certified, registered or licensed health care professional with expertise in diabetes, subject to the terms and conditions of the policy.

8 Methods Determining insurance coverage for DSM Education and DSM Support

9 Qualitative Methods Document review (Medicare) Key informant interviews (Medicaid & private)

10 Sampling Plan for Interviews States 2 most populous 8 random (2 from each region) Insurance companies 2 from each state Insurance plans 2 from each company

11 Interview Questions Domain DSM Education Interview Questions Does you plan provide coverage for diabetes self-management education classes or sessions with health professionals like a CDE or RD a? DSM Support Ongoing personal relationship with health professional Does your plan promote ongoing contact with a RD, CDE, or other nonphysician health professional? On demand access for health questions Does your plan provide diabetes patients with on-demand access for health questions, like a 24/7 nurse hotline? Proactive contact from a health professional Varied channels for diabetes information Referral to community resources Does your plan promote proactive contact from a health professional, like calling or mailing patients? Does your plan provide patients with access to diabetes information in multiple formats, like classes, written materials, and websites, for example? Does your plan refer diabetes patients to community resources, like support groups, safe places to exercise, or healthy cooking classes, for example?

12 Findings

13 Medicare: DSM Education 10 hours of training within a 12-month period 9 hours group education Accredited by the ADA, AADE, or IHS 3 hours Medical Nutrition Therapy with RD Participation restrictions Newly-diagnosed Started diabetes medications At risk for complications Physician referral

14 Medicare: DSM Support Ongoing relationship with health professional 2 hours follow-up DSM Education 2 hours Medical Nutrition Therapy Did not cover any other type of DSM Support

15 Medicaid: DSM Education N of 10 (%) DSM Education 5 (50%) Educational format Group DSM Education 2 Individual DSM Education with RD or CDE 1 Both group and individual education 2

16 Medicaid: DSM Support DSM Support N of 10 (%) Ongoing personal relationship with health professional 4 (40%) On demand access for health questions 1 (10%) 24/7 nurse hotlines 0 Phone lines, limited hours 1 On-line chat 0 Proactive contact from a health professional 0 (0%) Mailed appointment reminders 0 Varied channels for diabetes information 1 (10%) Referral to community resources 4 (40%) Support group referrals 3 Other resource referrals 4

17 Private Plans: DSM Education Premium N of 20 (%) Basic N of 20 (%) DSM Education 11 (55%) 11 (55%) Access Unlimited access to Education with copay 4 4 Restricted access to Education 7 7

18 Private Plans: DSM Support DSM Support Premium N of 20 (%) Basic N of 20 (%) Ongoing personal relationship with health professional 4 (20%) 2 (10%) On demand access for health questions 18 (90%) 17 (85%) 24/7 nurse hotlines Phone lines, limited hours 1 1 On-line chat 7 6 Proactive contact from a health professional 5 (25%) 3 (15%) Mailed appointment reminders 1 1 Varied channels for diabetes information 8 (40%) 8 (40%) Referral to community resources 10 (50%) 8 (40%) Support group referrals 8 8 Other resource referrals 8 7

19 Summary Medicare DSM Education 13 hours; physician referral DSM Support 4 hours; ongoing relationship Medicaid 50% (7-20 hours); physician referral Private 55%; limited access 40% ongoing relationship & comm. resource referrals 15% ongoing relationship; 88% on-demand access

20 Limitations Unrepresentative sample Does not reflect employee health plans Key informant data may not be accurate

21 Conclusions Coverage for DSM Education is limited Restrictions decrease accessibility Coverage for DSM Support is lacking On-demand access most covered component Ongoing relationships and proactive contact least covered components Coverage limitations exist despite state laws mandating insurance coverage for diabetes self-management education and training

22 Acknowledgements Funding sources: Robert Wood Johnson Diabetes Initiative Peers for Progress Thurston Arthritis Research Center Postdoctoral Fellowship Dr. Sandra Greene For more information:

23 References Austin MM. Diabetes educators: partners in diabetes care and management. Endocr Prac 2006;12: Brownson CA, Hoerger TJ, Fisher EB, Kilpatrick KE. Cost Effectiveness of Diabetes Self-Management Programs in Community Primary Care Settings. Diabetes Educ OnlineFirst; published on July 21, 2009 as doi: / Clement S. Diabetes self-management education. Diabetes Care 1995;18: Fisher EB, Brownson CA, O Toole ML, Anwuri VV. Ongoing follow-up and support for chronic disease management in the Robert Wood Johnson Foundation Diabetes Initiative. Diabetes Educ 2007;33(Suppl. 6):201S-207S. Fisher EB, Brownson CA, O'Toole ML, Shetty G, Anwuri VV, Glasgow RE. Ecologic approaches to self management: The case of diabetes. Am J Public Health 2005;95: Funnell MM, Brown TL, Childs BP, et al. National standards for diabetes self-management education. Diabetes Care 2009;32(Suppl. 1):S87-94 Muhlhauser I, Berger M. Diabetes education and insulin therapy: When will they ever learn? J Intern Med.1993;233: Norris SL, Lau J, Smith SJ, Schmid CH, Engelgau MM. Self-management education for adults with Type 2 Diabetes: A meta-analysis of the effect on glycemic control. Diabetes Care 2002;25: Pieber TR, Brunner GA, Schnedl WJ, Schattenberg S, Kaufman P, Krejs GJ. Evaluation of a structured outpatient group education program for intesnsive insulin therapy. Diabetes Care 1995;18: Piette JD, Glasgow R. Strategies for improving behavioral health outcomes among patients with diabetes: self-management, education. In: Gerstein HC, Haynes RB, eds. Evidence-Based Diabetes Care. Ontario, Canada: BC Decker Publishers; 2001: Rubin RR, Peyrot M, Saudek CD. Effect of diabetes education on self-care, metabolic control, and emotional well-being. Diabetes Care 1989;12: Rubin RR, Peyrot M, Saudek CD. The effect of a comprehensive diabetes education program incorporating coping skills training on emtional well-being and diabetes self-efficacy. Diabetes Educ 1993;19:

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