Facing today’s challenges in diabetes education
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September 25, 2008
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Facing today’s challenges in diabetes education
Access to care is one problem facing diabetes education; solutions are out there, according to some
educators.
Each year the number of Americans diagnosed with diabetes increases; however, some diabetes educators are struggl
with the challenge of sustaining their own businesses, faced with the reality that hospitals are cutting back or elimina
their diabetes education programs. Approximately 5% of ADA-recognized programs closed in 2006, according to an
American Association of Diabetes Educators Fact Sheet.
Hospitals state that the diabetes education programs can be costly and that fewer patients are interested. Diabetes
educators argue that patients may be unaware of the availability of these bene±cial programs and that there are ways
around the cost factor. Furthermore, diabetes educators can provide patients with the proper guidance, education and
diabetes self management tools from the start, which may ultimately help to reduce the number of in-hospital visits e
year due to diabetes-associated health complications.
“Diabetes is an ongoing disease. Life changes, treatment changes and management changes. Patients should be able t
receive ongoing education as it is needed,” said Virginia Zamudio Lange, RN, MSN, CDE,
a past president of the Amer
Association of Diabetes Educators.
“Diabetes costs a lot of money and diabetes educators are one of the solutions to this diabetes problem. We provide
patients with the tools and solutions to improve their lives. However, educators themselves are facing challenges that
may be preventing them from providing services,” Amparo Gonzalez, RN, BSN, CDE, president of the AADE, told
Endocrine Today
. Such challenges include ±nancial pressures, reimbursement issues, poor referrals from physicians,
decreased hours, issues with billing for diabetes self-management training and medical nutrition therapy, and a need
more educators.
Endocrine Today
interviewed several diabetes educators about a few of these pressures facing diabetes
education. Importantly, the professionals interviewed highlighted their e²orts and ideas for improvin
the present and future of diabetes education.
Gaps in care
“The discrepancies in the U.S. health care system have been identi±ed in numerous studies and article
over the years, and yet it seems that the gaps in quality care are widening as the number of people wit
diabetes increases,” Gonzalez wrote in an article published in a 2008 issue of The Diabetes Educator
.
According to Healthy People 2010, a governmental framework for national health care improvements
45% of people with diabetes received formal diabetes education in 1998. As a testament to the e³cacy
diabetes education, the 2010 objective is to increase this ±gure to 60%. Research backs up the notion that these educa
programs are e²ective; numerous published studies have demonstrated that diabetes self-management training lead
reductions in health care costs and hospitalizations and decreases health care utilization.
This article is more than 5 years old
. Information may no longer be current.
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Don
M. R
For example, Ed Wagner, MD,
and colleagues reported in a 2001 study published in JAMA
that a health plan that cover
diabetes education saved nearly $8 in health-related costs for patients with diabetes for every $1 invested in diabetes
education. They also reported a sustained reduction in HbA1c levels with regular self-management training.
Also in 2001, Susan L. Norris, MD,
and colleagues conducted a review of 72 studies to determine the
e²ectiveness of self-management training in patients with type 2 diabetes. “Collaborative interventions
focusing on knowledge tend to demonstrate positive e²ects on glycemic control in the short-term and mixed
results with follow-up of <1 year. Both individual and group lifestyle interventions had positive e²ects on diet
and self-care behaviors. It is notable that skills teaching were e²ective in both group and individual settings,”
they wrote in
Diabetes Care
.
Yet despite the e³cacy of formal diabetes education programs, diabetes educators remain underutilized, according to
Donna Rice, MBA, RN, BSN, CDE, immediate past president of the AADE and an Endocrine Today
Editorial Board memb
Access to care is one of the biggest issues facing diabetes educators today, according to Rice, who is an educator at
Botsford Center for Lifestyle Management, Novi, Mich.
“We need to increase awareness on the bene±ts of diabetes education because it is a bene±t [patients] have access to t
they do not always know about,” she said.
There are over 15,000 certi±ed diabetes educators in the United States and another estimated 15,000 diabetes educato
practice, according to the AADE. For every certi±ed diabetes educator, there are an estimated 1,600 patients in need of
services. Data from an AADE National Practice Survey from 2005 and 2006 showed that 63% of diabetes educators
reported seeing fewer than 500 patients per year, or two patient visits per day, and 42% reported seeing more than 1,0
patients per year, or four patients per day, according to the survey results (see chart)
.
“Even though you would think patients are knocking down our doors and waiting in line for education, the fact is, the
not,” said Mary Austin, MA, RD, CDE,
owner and president of The Austin Group, LLC, in Shelby Township, Mich and a
Endocrine Today
Editorial Board member.
Number of Patient Visits to Diabetes Educators in 2005 and 2006
Barriers
Austin suggested several barriers that may be contributing to the decline in patients receiving diabetes education. One
that patients are required to receive a referral by physicians in order to obtain the service. Patients may not be receivin
referrals to diabetes educators, and without that referral the service may or may not be a covered bene±t. Also, the
patient’s knowledge of diabetes education and their geographical proximity to a diabetes education care center can al
another limitation to receiving care.
“In order to really make money in diabetes education we have to have volume, just like any other business. A diabetes
education program without volume and a packed schedule will not be able to actually make money,” added Austin, wh
reported the AADE National Practice Survey results from 2006 with Malinda Peeples, RN, MS, CDE,
in The Diabetes
Educator
in 2007.
The Balanced Budget Act of 1997 provided coverage for diabetes self-management training. It expanded the types of
providers recognized to bill for diabetes education, which was previously only billable through hospital departments. Centers for Medicare and Medicaid Services issued a rule to implement expanded coverage of outpatient diabetes self-
management training, authorized by this act, and health plans soon followed suit.
One challenge in this arena is that Medicare will only cover diabetes education if it is ordered by the patients’ physicia
and included in the comprehensive plan of care. Physicians do not universally send all patients to diabetes self-
management training and may not understand the many bene±ts of education, according to Zamudio Lange, who is n
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Virginia
Zamudio Lange
RN, MSN, CDE
Virginia Zamud
Lange, RN, MSN
CDE, independe
diabetes consul
and member of
Endocrine Today
Editorial Board
Photo by M
G
Ma
Aus
MA,
CD
Mary
Aus
an independent diabetes consultant. Not all insurance carriers cover diabetes self management
education. Often, when a patient is referred, insurance may cover only a few hours of education per
year. Medicare, for example, covers one 10-hour initial training within a rolling 12-month period
and two hours of education every year after. However, many diabetes educators Endocrine Today
interviewed said that is not enough.
Certi±ed diabetes educators, unlike nurse practitioners or nurse midwives, for example, are not
recognized as care providers by Medicare and cannot bill for services directly, but must bill through
a hospital or physician o³ce. However, dietitians are recognized providers and are allowed to bill
CMS for medical nutrition therapy services.
“If certi±ed diabetes educators could bill directly, there would be tens of thousands more educators
that could serve patients who are not currently receiving education. This would open up access and
help me and my colleagues have a more viable livelihood,” Zamudio Lange told Endocrine Today
.
Diabetes educators use HCPCS G codes to bill Medicare for diabetes self-management training: G0108 and G0109. In 2
the participating physician allowance for G0108 under the Medicare fee schedule was $63.13 and the corresponding
allowance for G0109 was $37.11. A group of just three Medicare bene±ciaries would generate $111.33 for 30 minutes of
training, according to an article written by Kent J. Moore, manager of health care ±nancing and delivery systems for t
American Academy of Family Physicians.
According to Gonzalez, about a third of patients with diabetes are covered by Medicare, one-third are covered by priva
insurance and one-third of patients do not have any insurance. However, there are services and programs for patients
without insurance. In 2005, 26% of diabetes education programs were reimbursed by Medicare and 19% reimbursed b
managed care, according to ±ndings from the AADE National Practice Survey. Results from the 2007 National Practice
Survey appear to be reporting similar trends.
“Let’s be realistic. Large centers that are doing a substantial amount of billing should be viable. But the majority of
education programs are not large programs in hospitals; most are outpatient clinics or private, totally at the mercy of
referrals if the educators are counting only the money made from actual education,” Austin said.
In 2005, the Centers for Medicare and Medicaid Services reimbursed $4.8 million for diabetes self-management train
costs, according to AADE statistics. About 42% of managers reported that their program operated at a loss, and 14%
reported their program operated at a pro±t, according to the survey ±ndings.
“In an ideal world, as diabetes educators we could tailor our programs to the needs of the patient, and the reimbursem
fees for the services provided would be enough to cover our costs and allow us to have a good ±nancial model in diabe
education,” Gonzalez told Endocrine Today
.
Addressing these challenges
What are some possible solutions to the issues outlined above? Many diabetes educators are seeking ways to
capitalize on new directions and opportunities, face these challenges, and improve the care they provide.
Moving diabetes education into nontraditional settings may o²er one solution. Education “must move away
from the hospitals and out into communities where the people with diabetes play and work,” Gonzalez
suggested during the AADE 35th Annual Meeting in August. These settings may include retail clinics in large
stores such as Wal-Mart and Target, and community- and employee-based wellness centers. Di²erent
settings can open up new opportunities for educators to connect with patients and help create new educator job
opportunities, according to Gonzalez.
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Ala
Gar
“Expand the wall and move your program out. Diabetes is growing, your business should be growing, too,” said Rice. is how she overcame the barriers at her diabetes program, where educators are right in the physician’s o³ces where t
patients are.
Nearly all of the diabetes educators Endocrine Today
interviewed said an improved partnership between physicians an
educators is essential for diabetes education to be sustained.
“It would be great if diabetes educators and endocrinologists could really join forces and work closer. There are many
opportunities to take it to a higher level,” Gonzalez said.
The future of diabetes education must also include more training and recruitment of recent graduates to enter the ±el
Many diabetes educators say they just fell into diabetes education. The AADE is currently developing a more concrete
career path into diabetes education. “We know the epidemic is out there, but we need to focus on moving more people
education,” Rice said.
The AADE supports diabetes educators and the organization is developing several initiatives, such as primary care
practice programs to deliver diabetes self-management training in a variety of settings, multi-level career path
guidelines and an Entrepreneurial Training Toolbox to help members develop their own businesses.
As for the ±nancial aspects that may hinder diabetes education programs, Gonzalez said, “The AADE is fully aware an
concerned with the revenue model, and we are having conversations with federal agencies to address the issue, and th
are listening. Solutions will not come overnight, but we are de±nitely moving in the right direction in being heard abo
this issue.”
The AADE is working to pass legislation that would allow Medicare to recognize certi±ed diabetes educators as provid
In addition, CMS’s 9th Statement of Work will focus on diabetes self-management.
“In other words, e²orts are underway to help improve this current situation,” Gonzalez said.
As it stands, however, “diabetes education as we know it today will need to change if it is to serve the ever-growing
number of people with diabetes in the United States,” Austin said. – by Katie Kalvaitis
Is diabetes education truly pro±table?
Patients must take responsibility for their own health: Perspective from Endocrine Today
’s Chief Medical Editor
The current crisis in diabetes education reveals a fatal ´aw in the present system of employer-sponsored
health care plans that cannot be overcome by transforming more insured out of uninsured patients. The
problem is that patients see themselves as having little or no responsibility for their own health care or its
outcomes. Consequently, if it is not covered by their insurance they do not believe it necessary for themselves
to arrange this education. This is an impossible situation to continue, as the demand will only escalate for
more and more services that must be free or minimally charged to the patient; otherwise they go unful±lled.
When patients take more responsibility for themselves and arrange for necessary services, out of pocket if necessary, there will be more education. Health plans with more educational bene±ts cost more than plans without such bene±ts
Most commonly, patients select from a menu of health care plans the least expensive rather than the most bene±cial
plans. Patients must be willing to pay for such bene±cial plans and bene±ts; otherwise they will disappear from the
marketplace, no matter how necessary we believe these services to be. Government funding of health care only worse
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this already intolerable situation since it ampli±es the concept that someone other than the patient is responsible for
funding the patient’s health care. This is a concept that, like the bread and circuses of Ancient Rome, undermines and
weakens rather than strengthens the structure of its society.
– Alan J. Garber, MD,
Professor in the Departments of Medicine, Biochemistry and Molecular Bio
and Cellular & Molecular Biology at Baylor College of Medicine, Hou
and Chief Medical Editor of Endocrine T
For more information:
Zamudio American Diabetes Association. Third-party reimbursement for diabetes care, self-management educatio
and supplies.
Diabetes Care
. 2003;26:143-144.
Bartlett E. Historical glimpses of patient education in the United States. Patient Educ Counsel
. 1986:8:135-149.
Bourgeois P. Insurance: what our patients need to know. Diabetes Spectrum
. 2005;18:62-64.
Gonzalez A. Diabetes education for all! Diabetes Educ
. 2008;34:373.
Moore KJ. Billing Medicare for diabetes self-management training. Fam Pract Manag
.
2001;
www.aafp.org/fpm/20010400/14bill.html
.
Norris SL, Engelgau MM and Narayan KMV. E²ectiveness of self-management training in type 2 diabetes. Diabetes
Care
. 2001;24:561-587.
Peeples M and Austin MM. Toward describing practice: The AADE National Diabetes Education Practice Survey:
diabetes education in the United States – who, what, where and how. Diabetes Educ
. 2007;33:424-433.
Wagner EH, Sandhu N, Newton KM, et al. E²ect of improved glycemic control on health care costs and utilization.
JAMA
. 2001;285:182-189.