Third-party reimbursement for diabetes care, self-management education, and supplies.

D iabetes is a chronic disease that affects nearly 17 million Americans (1), with over 10 million cases diagnosed, and is characterized by serious, costly, and potentially fatal complications. The total cost of diagnosed cases of diabetes in the U.S. in 2002 was estimated to be $92 billion (1). To prevent or delay the costly complications and to enable people with diabetes to lead healthy, productive lives, appropriate medical care based on current standards of practice, self-management education, and medication and supplies must be available to everyone with diabetes. This paper is based on technical reviews titled “Diabetes SelfManagement Education” (2) and “National Standards for Diabetes SelfManagement Education Programs” (3). The goal of medical care for people with diabetes is to optimize glycemic control and minimize complications. The Diabetes Control and Complications Trial (DCCT) demonstrated that treatment that maintains blood glucose levels near normal in type 1 diabetes delays the onset and reduces the progression of microvascular complications. The U.K. Prospective Diabetes Study (UKPDS) documented that optimal glycemic control can also benefit most individuals with type 2 diabetes. To achieve optimal glucose control, the person with diabetes must be able to access health care providers who have expertise in the field of diabetes. Treatment plans must include selfmanagement training, regular and timely laboratory evaluations, medical nutrition therapy, appropriately prescribed medication(s), and regular self-monitoring of blood glucose (SMBG) levels. The American Diabetes Association position statement “Standards of Medical Care for Patients with Diabetes Mellitus” outlines appropriate medical care for people with diabetes (4). An integral component of the DCCT was self-management education (inpatient and/or outpatient) delivered by an interdisciplinary team. Self-management training also helps people with type 2 diabetes adjust their daily regimen to improve glycemic control. Diabetes selfmanagement education is the process of providing the person with diabetes with the knowledge and skills to perform self-care on a day-to-day basis. Selfmanagement education teaches the person with diabetes to assess the relationships among medical nutrition therapy, activity level, emotional and physical status, and medications and then respond appropriately and continually to those factors to achieve and maintain optimal glucose control. Today, self-management education is a critical part of the medical plan for people with diabetes, such that medical treatment of diabetes without systematic selfmanagement education cannot be regarded as acceptable care. The National Standards for Diabetes Self-Management Education Programs establish specific criteria against which diabetes education programs can be measured, and a quality assurance program has been developed and subsequently revised (5). Treatments and therapies that improve glycemic control and reduce the complications of diabetes will also significantly reduce health care costs (6,7). Numerous studies have demonstrated that self-management education leads to reductions in the costs associated with all types of diabetes. Participants in selfmanagement education programs have been found to have decreased lowerextremity amputation rates, reduced medication costs, and fewer emergency room visits and hospitalizations. Access to the integral components of diabetes care, such as health care visits, diabetes supplies and medications, and self-management education, is essential. The American Diabetes Association believes insurers must reimburse for medical treatment and also for selfmanagement education programs that have met accepted standards, such as the American Diabetes Association’s National Standards for Diabetes Self-Management Education Programs. All medications and supplies, such as syringes, strips, and meters, related to the daily care of diabetes must also be reimbursed by thirdparty payers. Organizations that purchase health care benefits for their members or employees should insist that selfmanagement education, medications, and supplies be included in the services provided, and managed care organizations should include these services and supplies in the basic plan available to all participants. It is recognized that the use of formularies, prior authorization, and related provisions (hereafter referred to as “controls”), such as competitive bidding, can manage provider practices as well as costs to the potential benefit of payors and patients. Social Security Act Title XIX, section 1927, states that excluded agents should not have “a significant clinically meaningful therapeutic advantage in terms of safety, effectiveness or clinical ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●