Publications and Products
The Economics of Diabetes Mellitus:
An Annotated Bibliography
POLICY/POSITION
STATEMENTS RELATED TO DIABETES
227
TITLE:
American Diabetes Association Annual Meeting 1996: Managed Care and Change
in Medicine. Bloomgarden, Z.T. Diabetes Care. 19(10): 1169–1173.
October 1996.
OBJECTIVE:
To review presentations at the 1996 meeting of the American Diabetes Association
(ADA) about managed care and changes in health care delivery.
CATEGORY:
Policy/position statement.
CONCLUSION:
Various presentations at the meeting are discussed.
RECOMMENDATION:
None.
ABSTRACT:
At the annual meeting of the ADA, the president of the association, Frank
Vinicor, asserted that the United States does not perceive diabetes to
be high risk (i.e., a transmissible disorder) or economically important.
Edward Wagner, of Group Health of Puget Sound, advocated a population-based
approach to diabetes care focused on preventing complications and reaching
all patients. He considered it critical to define the subset of patients
who need a specialist. Another speaker, Neal Friedman, advocated critical
pathways for decision making, which lower inter-physician variability,
increase cost efficiency, and improve outcomes. Dr. Friedman recommended
using experts from other industries in the quality assurance process,
as well as focus groups. He stressed data management and emphasized using
the database to improve quality. His clinic in New Mexico uses disease
management for the 30 most expensive diseases, which include diabetes.
Also at the meeting, the potential adverse impact of managed care practices
on diabetes care was addressed. Alan Jacobson, of Boston, raised the possibility
that diabetes care may become similar to that of mental health disorders
under managed care, with carve-out for-profit specialty companies drastically
limiting patient access to specialty care. The subprograms of the Diabetes
Control Network, a program that was publicized by both the Pfizer drug
company and the ADA, were detailed. This program includes practice guidelines
for primary physicians in managed care organizations and a computer program
that models future medical costs and potential quality control strategies.
Other issues addressed at the meeting included the disproportionately
high use of medical resources by patients with diabetes, inadequate and
variable reimbursement for preventive and self-management methods, and
deficiencies in the current treatment of diabetes, particularly in screening
for complications.
228
TITLE:
Medicare Supplement Plan Required to Cover Diabetes. Minnesota Medicine.
78(12): 40. December 1995.
OBJECTIVE:
To describe a new law governing Medicare supplemental insurance plans.
CATEGORY:
Policy/position statement.
CONCLUSION:
The law will help the elderly afford preventive testing and management
supplies they need for diabetes care.
RECOMMENDATION:
Accepted standards of care ought to be covered by insurance policies.
ABSTRACT:
Medicare supplemental insurance plans are now required to cover the cost
of supplies and equipment necessary to treat diabetes. Previous law required
only that health plans cover "all physician-prescribed, medically
appropriate and necessary" equipment and supplies used to manage
and treat diabetes. The change takes effect for those plans issued or
renewed on or after January 1, 1996. In Minnesota, 45 percent of persons
diagnosed with diabetes are aged 65 or over. According to the Minnesota
chapter of the American Diabetes Association (ADA), the new law will make
it easier for the elderly to afford the preventive testing and management
supplies they need to control their diabetes and reduce the risk of complications.
According to the chair of the government relations committee of the ADA,
the new law will greatly improve access to appropriate medical care for
the patient with diabetes.
229
TITLE:
Budget Trends and Issues Affecting Biomedical Research: A Perspective
from the National Institute of Diabetes and Digestive and Kidney Diseases.
Gorden, P.; Cyphers, D.F.; Feld, C. Hepatology. 18(3): 677–687.
September 1993.
OBJECTIVE:
To review the federal budget process for research from the perspective
of the National Institute of Diabetes and Digestive and Kidney Diseases
(NIDDK).
CATEGORY:
Policy/position statement.
CONCLUSION:
The federal deficit and debt and associated cost containment and cost
management principles will continue to have a major impact on the National
Institutes of Health (NIH) budget, limiting the size of research grants.
RECOMMENDATION:
None.
ABSTRACT:
The authors describe the NIH budget process and review historical developments.
In the late 1980s, NIH funding became more constrained, but average grant
size continued to rise; the duration of grant awards increased, and the
number of applications rose. In response to congressional concerns about
rising grant costs and approval rates, the NIH developed the NIH Financial
Management Plan (1991). The plan limits the percentage increase in grant
size to the rate of inflation, adjusts grant budgets on a case-by-case
basis, and limits the length of an award to 4 years. From 1987 to 1993,
the NIDDK's appropriation in constant dollars was virtually flat. The
institute has become increasingly committed to investigator-initiated
research and to the NIH peer review system for making funding decisions
based on scientific merit. The NIDDK will need to continue to conceptualize
and justify its research portfolio in terms of major cross-cutting categories
of interest to the public, the administration, and Congress, such as research
in the areas of prevention and women's and minority health. To the extent
that the NIDDK can compete successfully for trans-NIH funds, it will increase
its own funding and help its constituencies. With limited funding for
grants likely to continue, other funding options will be explored: cofunding;
smaller, short-term awards; a sliding-scale approach to paying grant costs;
cost containment incentives; caps on salaries and other costs; and reducing
indirect costs. 6 figures, 2 tables, 6 references.
230
TITLE:
CDC Diabetes Control Programs — Overview of Diabetes Patient Education.
Alogna, M. The Diabetes Educator. 10(4): 32–36,
57. Winter 1985.
OBJECTIVE:
To describe the planning process for the development of diabetes patient
education programs in state Diabetes Control Programs (DCPs) supported
by the Centers for Disease Control (CDC).
CATEGORY:
Policy/position statement.
CONCLUSION:
Preliminary results from state Diabetes Control Programs show that education
interventions have increased knowledge, improved self-management skills,
reduced hospitalizations, and lowered costs.
RECOMMENDATION:
None.
ABSTRACT:
The CDC established its DPCP in 20 states in 1977 on the recommendation
of the National Commission on Diabetes. The goal of the DPCP was to reduce
mortality, morbidity, and cost burden from preventable complications of
diabetes at the community level. As part of this effort, CDC collected
data from participating states on mortality, morbidity, and available
resources as well as problems in controlling patients with diabetes and
factors contributing to those problems. These data showed a lack of outpatient
education programs; in most states, inpatient education was offered at
more than 80 percent of hospitals but outpatient education at less than
25 percent. Inspection of Utah programs revealed that smaller hospitals
there were less likely to have written teaching plans, formal follow-up
of patients, and support groups. An inquiry into education in Ohio found
that simple measures such as return demonstration and repetition and preassessments
and postassessments were used most frequently. The least-used evaluation
methods were monitoring the number of hospital admissions or emergency
room visits. The states formed a working group to develop recommendations
for quality patient education and process and outcome evaluation. As a
result, the CDC developed the CDC-State Patient and Professional Education
Guidelines to be used in evaluating existing programs, developing new
programs, promoting reimbursement, and providing a guide for program certification.
The CDC guide also served as a basis for Patient Education Standards later
developed by the National Diabetes Advisory Board. Numerous other materials,
manuals, assessment tools, instruments, and standards of care for diabetes
care and education have been developed. The author describes diabetes
education activities undertaken in the individual states with a DPCP. 2
tables, 6 references.
231
TITLE:
Coverage of Diabetes Education Programs. Health Care Financing Administration
Memorandum dated August 25, 1987. U.S. Department of Health and Human
Services, Public Health Service, Health Care Financing Administration,
Office of Coverage Policy, Bureau of Eligibility, Reimbursement &
Coverage.
OBJECTIVE:
To detail Medicare coverage of outpatient diabetes education programs.
CATEGORY:
Policy/position statement.
CONCLUSION:
Outpatient hospital diabetes education programs located in a hospital
or rural health clinic are covered under Part B of the Medicare program.
Programs must be closely related to the care and treatment of individual
patients.
RECOMMENDATION:
Intermediaries for Medicare should be making coverage decisions.
ABSTRACT:
In this memorandum, the author, Robert E. Wren of the Health Care Financing
Administration, responds to an inquiry from the Regional Administrator
in Dallas, Texas, about Medicare coverage of outpatient diabetes education
programs. The author notes that Section 801 of the Coverage Issues Manual
provides a useful framework for intermediaries in the claims review process.
He also states that outpatient hospital education programs may be covered
by Medicare if services are ordered by a physician, given by the provider's
personnel, supervised by the medical staff, and rendered to registered
patients of that provider. The services must be closely related to the
care and treatment of the individual patient and must provide essential
skills and knowledge that will aid in the patient's active participation
in his/her own treatment. In general, patients likely to be suitable for
such education efforts would be those newly diagnosed with diabetes, persons
with unstable diabetes, and those with longterm diabetes who have current
management problems. Long-term patients with stable diabetes would not
likely be candidates. Programs should be relatively brief, with entrance
by physician referral only. A letter to David C. Warner, Chairman of the
Texas Diabetes Council, is appended in which Mr. Wren goes over many of
the same points.
232
TITLE:
Diabetes Outpatient Education: The Evidence of Cost Savings. American
Diabetes Association Task Force on Financing Quality Health Care for Persons
with Diabetes. 1986. 4 pp.
OBJECTIVE:
To document evidence of cost savings resulting from diabetes education;
to report the existence of standards for assuring quality educational
programs.
CATEGORY:
Policy/position statement.
CONCLUSION:
Diabetes education is now recognized as an integral component of treatment
that results in cost savings and improved quality of life. The quality
of an education program is assured by the existence of certification exams
for educators, national standards and criteria for programs, and a recognition
process for programs that meet the standards.
RECOMMENDATION:
None.
ABSTRACT:
This report summarizes reported evidence of cost savings achieved through
diabetes outpatient education. Much of the economic cost of diabetes is
due to short- and long-term complications. Outpatient education in self-care
leads to improved blood glucose control, self-care skills, and adherence
to treatment regimens and reduces morbidity and premature mortality associated
with diabetes and its complications. A record audit of 78 consecutive
community hospital admissions for complications due to diabetes found
that 27 percent of these admissions occurred because of a specific educational
deficit. Lack of reimbursement is the most significant barrier to the
development of outpatient education programs. The American Diabetes Association,
American Hospital Association, National Diabetes Advisory Board, American
Public Health Association, and the American Association of Diabetes Educators
have all endorsed the concept of patient education as an integral part
of diabetes treatment. Many studies on outpatient education show that
these programs are clinically and cost effective. National standards for
diabetes patient education programs have been developed, and a recognition
process has been established for programs meeting the standards. In addition,
a certification process for diabetes educators has been implemented. An
increasing number of insurers are recognizing diabetes outpatient education
as a reimbursable benefit. 2 tables, 23 references.
233
TITLE:
Evaluative Approaches to Type II Diabetes. Triomphe, A. PharmacoEconomics.
8(Supplement 1): 58–61.
1995.
OBJECTIVE:
To review major methods for evaluating the economic efficiency of diabetes
therapy and educational programs.
CATEGORY:
Policy/position statement.
CONCLUSION:
The economic evaluation of type 2 diabetes could play an important role
in making management decisions about the disease. Yet, results of economic
analyses should be used cautiously.
RECOMMENDATION:
A more consistent application of recent methods of economic evaluations
could improve understanding of the economic consequences of type 2 diabetes.
ABSTRACT:
The author asserts that there are still very few economic evaluation studies
on diabetes, especially type 2 diabetes. Cost-of-illness, the simplest
form of economic evaluation, considers costs but not outcomes of therapy.
Cost-effectiveness, cost-utility, and cost-benefit analyses are the major
methods of evaluating the economic efficacy of diabetes therapy and educational
programs. All three methods express costs in monetary terms, but they
differ in the way they assess outcomes. In cost-effectiveness analysis,
the efficiencies of interventions, treatments, or control programs are
compared; and the health outcomes of the interventions are measured in
physical units. Cost-utility analysis usually summarizes health outcomes
in quality-adjusted life years saved. Cost-benefit analysis places a monetary
value on the health outcomes of a program or therapy and can be used to
compare the benefits and opportunity costs of a program. The quantity
of health obtained is usually valued in terms of work productivity gained,
which is generally measured by average wages. An alternative approach
is to value life or health with a "willingness to pay" approach.
The author notes that prevention programs are commonly held to save money
over the long term, but she reports that they generally cost more than
they save. She states the economic issue for discussion is not whether
prevention saves money but whether it improves health at a reasonable
cost. 1 table, 9 references.
234
TITLE:
Improving the Financing of Diabetes Care in the 1990s: Recommendations
of the 1989 Conference. Bransome, E.D. Diabetes Care.
15(Supplement 1): 66–72.
March 1992.
OBJECTIVE:
To report on the financing problems identified by the 1989 Conference
on Financing the Care of Diabetes Mellitus in the 1990s and on the recommendations
for action made at the conference.
CATEGORY:
Policy/position statement.
CONCLUSION:
Major problems evident in the financing of diabetes care include lack
of an adequate chronic disease model, inadequate communication between
the treatment and reimbursement communities, and absence of data demonstrating
the cost-effectiveness of diabetes care.
RECOMMENDATION:
Develop a health care delivery model appropriate for diabetes, establish
better communication mechanisms between the diabetes and reimbursement
communities, and expand the database of information pertinent to diabetes
care reimbursement activity.
ABSTRACT:
The author reviews problems identified by participants in a conference
workshop on the financing of diabetes care as well as their recommendations
to address these problems. The prevailing acute disease model is not applicable
to diabetes care, which involves ongoing, mostly outpatient services.
Communication between reimbursers and the diabetes community is often
ineffective, with health care professionals focusing on quality of care
and service delivery and insurers on cost containment. A national forum
is needed to involve both parties in the reimbursement decision-making
process and ensure ongoing communication. Most patients with diabetes
do not receive care that meets the current standards established by the
American Diabetes Association and the Centers for Disease Control (CDC).
Standards of care should be reviewed and updated in a timely fashion and
widely disseminated to health care professionals and reimbursers. The
diabetes community should work with the Health Care Financing Administration
to expand reimbursement for patient education to Medicare beneficiaries.
It should also support efforts to include reimbursement costs for patient
education in services provided by nonphysicians. Patients are not meaningfully
involved in the reimbursement decision-making process. Informed consumers
should have input along with health care professionals working to implement
standards of care. Insufficient data are available to document the cost-effectiveness
of diabetes care. The CDC's database on reimbursement activity should
be expanded to include data on program costs, outcomes of various delivery
systems, cost-effectiveness and cost-benefit studies, and health care
utilization patterns. 7 references, 2 appendixes.
235
TITLE:
Medical Technology and Costs of the Medicare Program. Office of Technology
Assessment, U.S. Congress, Washington, DC. July 1984. 230 pp.
OBJECTIVE:
To review policy mechanisms for limiting or reducing Medicare costs related
to technology.
CATEGORY:
Policy/position statement.
CONCLUSION:
Medicare policies increase the use of medical technologies, and the use
of medical technologies significantly affects Medicare costs.
RECOMMENDATION:
The authors make several suggestions for restraining the rise in Medicare
costs by changing the incentives for adopting and using technology.
ABSTRACT:
The authors define medical technologies as the drugs, devices, and medical
and surgical procedures used in medical care as well as the organizational
and supportive systems in which such care is provided. Medical technology
has been a primary cause of the rapid escalation in U.S. health care costs
over the past 15 years. Medicare policies affect the adoption and use
of medical technologies and, conversely, patterns and levels of use of
Medicare technologies significantly affect Medicare costs. In this report,
the Congressional Office of Technology Assessment identifies possible
areas for changes in Medicare policies that could be used to influence
the adoption and use of medical technology and to restrain Medicare costs:
coverage policy for specific technologies, methods of payment to hospitals,
methods of payment to physicians, and approaches to changing the incentives
for adopting and using technology that do not directly involve the Medicare
payment system (e.g., alternative delivery systems). Efforts to curb the
escalation in Medicare costs and control the diffusion of medical technology
have been largely ineffective to date. There are numerous incentives in
Medicare's benefit policy to provide too many of some kinds of technologies
and too few of others. The authors note Medicare's policy of not explicitly
considering cost or cost-effectiveness in making coverage decisions; Medicare
also has refrained from limiting coverage of particular technologies to
specific institutions or to physicians with specific skills. 29 tables,
3 figures, 5 appendices, 437 references.
236
TITLE:
The National Long-Range Plan to Combat Diabetes, 1987. National Diabetes
Advisory Board, U.S. Department of Health and Human Services, Public Health
Service, National Institutes of Health. Washington, DC, 1987. 76 pp.
OBJECTIVE:
To set forth a long-range plan to combat diabetes mellitus that includes
research, national goals, the translation of research findings to patient
care, a review of accomplishments and future directions, and the role
of the private sector.
CATEGORY:
Policy/position statement.
CONCLUSION:
None.
RECOMMENDATION:
Numerous recommendations are set forth in the body of the report.
ABSTRACT:
The National Diabetes Advisory Board, whose members (scientists, physicians,
other health professionals, members of the general public) are appointed
by the Secretary, Department of Health and Human Services, set forth recommendations
in research, patient care, and other areas. In research, the Board recommended
the development of eight interdisciplinary research programs, a biologic
resource bank for studies on diabetes, and an information and data system
for Diabetes Research. The objective of the interdisciplinary programs
is to promote the rapid integration of newly developed methodologies of
the basic sciences into diabetes-related research. Various recommendations
are made to continue and strengthen current programs: for example, the
Board recommended that adequate funds be appropriated to institutes of
the National Institutes of Health to support at least 50 percent of approved
diabetes-related, competing, individual research grants at budget levels
approved by the scientific review committees; it is also recommended that
the National Institute of Diabetes and Digestive and Kidney Diseases receive
adequate funding to complete the Diabetes Control and Complications Trial
as planned. In the section on diabetes goals for the nation, the Board
recommended that consensus be reached on treatment guidelines for the
diabetes patient without complications and that guidelines for the management
of patients with complications be developed. In diabetes translation,
the Board recommended that a Diabetes Translation Center be established
at the Centers for Disease Control. In the section on the private sector,
the Board recommended that this sector increase financial and human participation
in Diabetes Research.
237
TITLE:
National Standards and Review Criteria for Diabetes Patient Education
Programs: Quality Assurance for Diabetes Patient Education. National Diabetes
Advisory Board. Diabetes Educator. 12(3): 286–291.
Summer 1986.
OBJECTIVE:
To define the standards and review criteria for a diabetes patient education
program.
CATEGORY:
Policy/position statement.
CONCLUSION:
None.
RECOMMENDATION:
None.
ABSTRACT:
Ten standards developed under the aegis of the National Diabetes Advisory
Board and endorsed by the diabetes community are presented. (1) Needs
assessment: This activity should guide program management and form the
basis for program planning. (2) Planning: The planning process should
describe the program's goals and objectives, target audience, setting,
referral mechanisms, procedures, and evaluation methods. (3) Program management:
The ultimate responsibility should lie with the designated program coordinator.
(4) Communications/coordination: A physician should act as liaison between
the medical staff and the program coordinator. (5) Patient access to teaching:
Both patients and staff should be routinely informed about self-care programs.
(6) Content/curriculum: The individual needs assessment provides the basis
for a patient's instructional program. (7) Instructor: Instructors should
be skilled professionals with recent experience and training in diabetes
and educational principles. (8) Follow-up: Written communication between
program staff and primary physicians is essential for identifying the
patient's needs. (9) Evaluation: Review should be conducted by an advisory
committee made up of at least one of each of the following: physician,
nurse (or qualified diabetes health educator), dietitian, consumer, and
the patient education program coordinator. (10) Documentation: All information
about the patient's educational experience should be documented in the
patient's permanent medical or educational record.
238
TITLE:
New Approaches to Medical Technology Coverage: Conference Proceedings.
Miller, J.E. Health Insurance Association of America. 48 pp. April 1991.
OBJECTIVE:
To provide a synopsis of the proceedings of a 1990 conference on medical
technology coverage sponsored by the Health Insurance Association of America.
CATEGORY:
Policy/position statement.
CONCLUSION:
Insurers must try to balance cost control, resource utilization, and quality
of care as they make coverage and payment decisions.
RECOMMENDATION:
Insurers must develop the will and ability to adapt to pressures for faster
and more open coverage processes.
ABSTRACT:
The author synopsizes the proceedings of the 1990 conference "New
Approaches to Medical Technology Coverage" sponsored by the Health
Insurance Association of America. Topics included the ethics of technology
assessment, insurance coverage issues and innovative approaches to coverage
decisions, law and policy, evaluating the clinical effectiveness of screening
tests, designation of qualified centers for specialized services, and
methodologies and applications of quality assessment. The controversy
surrounding the development and use of medical practice guidelines was
debated, with opinions offered by representatives of the medical and insurance
communities. The issue of coverage policy relative to a technology's cost-effectiveness
was also addressed. Cost-benefit and cost-analysis data were noted to
be inadequate in many areas of health care, and it was suggested that
such studies be conducted not only by the government but also by companies
seeking to market new drugs and technologies.
239
TITLE:
Office Visits for Diabetes Mellitus: United States, 1989. Schappert, S.M.
Advance Data from Vital and Health Statistics of the National Center
for Health Statistics; No. 211. 12 pp. March 24, 1992.
OBJECTIVE:
To present national estimates of diabetes-related office visits in the
United States in 1989.
CATEGORY:
Policy/position statement.
CONCLUSION:
During the study period, there were an estimated 13.2 million visits to
nonfederally-employed, office-based physicians in the United States in
which the principal diagnosis was diabetes mellitus.
RECOMMENDATION:
None.
ABSTRACT:
The author reports on estimates of diabetes-related office visits in the
United States for the 12-month period of March 1989 to March 1990. Data
were derived from the National Ambulatory Medical Care Survey. During
the study period, there were an estimated 13.2 million visits made to
nonfederally-employed, office-based physicians at which the principal
(first-listed) diagnosis was diabetes mellitus. More than half (57.5 percent)
of these visits were made by females, and 86.3 percent were made by persons
aged 45 years and older; 79.3 percent of visits were made by white persons.
Forty-four percent of visits were made to general or family practice physicians.
Internal medicine specialists received 28.7 percent of visits, and ophthalmologists
received 6.8 percent. Patients making return visits to the physician for
care of their condition accounted for 92.2 percent of the 13.2 million
office visits. During the study period, diabetes mellitus was the second-
or third-listed diagnosis for an additional 8.7 million office visits.
For all office visits in 1989, diabetes mellitus was the seventh most
frequently reported principal diagnosis but the fourth most frequently
reported morbidity-related principal diagnosis (essential hypertension,
otitis media, and acute upper respiratory infections were the first three).
Approximately 72 percent of visits with a principal diagnosis of diabetes
mellitus included a blood pressure check; other frequently performed diagnostic
services on these visits included "other" blood tests, urinalysis,
cholesterol measure, and visual acuity examination. Weight reduction was
the most frequently reported type of counseling/advice ordered or provided.
3 figures, 18 tables, 7 references, 1 technical note with 3 tables.
240
TITLE:
Practice Guidelines for Nutrition Care by Dietetics Practitioners for
Outpatients with Non-Insulin-Dependent Diabetes Mellitus: Consensus Statement.
Franz, M.J. Journal of the American Dietetic Association. 92(9):
11361139. September 1992.
OBJECTIVE:
To present practice guidelines for nutrition care to dietetic practitioners
who treat outpatients with type 2 diabetes.
CATEGORY:
Policy/position statement.
CONCLUSION:
Nutrition practice guidelines provide a road map for nutrition care that
allows for consistency in the individualized care of people with type
2 diabetes.
RECOMMENDATION:
Patients with type 2 diabetes should be referred to a registered dietitian
within the first month after diagnosis, with a follow-up visit at two
to four weeks and semiannual or annual visits thereafter. Physicians should
supply the registered dietitian with information on diagnosis, treatment
modalities and response to date, laboratory values, medical clearance
or limitations for exercise, and, if appropriate, psychological or economic
data.
ABSTRACT:
The American Dietetic Association contracted with the International Diabetes
Center (IDC) in Minneapolis, Minnesota, to develop, fieldtest, and evaluate
nutrition care practice guidelines. This article is the report of an interdisciplinary
consensus panel of experts chaired by the IDC's M.J. Franz, which met
in Minneapolis in October 1991. The panel was charged with addressing
several critical questions: (1) What are realistic outpatient nutrition
care practice guidelines for persons with type 2 diabetes? (2) What decisions
are the responsibility of the physician? Of the registered dietitian?
(3) What are the expected outcomes related to the nutrition practice guidelines?
(4) What is usual nutrition care in the United States for persons with
type 2 diabetes? The panel concluded that registered dietitians should
determine an appropriate diet prescription for the patient and select
appropriate educational materials and interventions. It was determined
that two-way communication between the physician and the registered dietitian
is critical and that medical outcomes should be evaluated to determine
the effectiveness and cost of treatment. Implementing therapeutic advice
is important for patients, but how patients view their quality of life
may be equally important. In evaluating usual nutrition care in the United
States for persons with type 2 diabetes, the panel found that initial
nutrition information is provided by the physician, nurse, or registered
dietitian. Physicians may spend approximately five minutes handing out
diet sheets, but they solicit little if any information from patients
about convenience or their ability to follow the meal plan. Another frequent
option is for the nurse to spend 10 to 20 minutes providing initial nutrition
information. In a 1989-1990 physician survey conducted by the National
Institute of Diabetes and Digestive and Kidney Diseases, a majority of
respondents said they referred patients with type 2 diabetes to registered
dietitians, but it is not known how may patients actually see a dietitian.
17 references.
241
TITLE:
Practice Guidelines for Nutrition Care by Dietetics Practitioners for
Outpatients with Non-Insulin-Dependent Diabetes Mellitus: Methodologies
for Field Testing and Cost Effectiveness Analysis. Mazze, R.S.; Franz,
M.J.; Monk, A.; Cooper, N.; Barry, B.; Weaver, T.; McClain, K.; Upham,
P.; Haugen, D.; Bergenstal, R. Journal of the American Dietetic Association.
92(9): 11391142. September 1992.
OBJECTIVE:
To describe a clinical study designed to assess the impact of nutrition
care on persons with type 2 diabetes.
CATEGORY:
Policy/position statement.
CONCLUSION:
The study is expected to yield information that will help physicians and
dietitians better understand the nature of nutrition care in diabetes
management. Designing and implementing the nutrition protocols has already
yielded important information, such as a consensus as to what is meant
by basic and intensive nutrition care for people with type 2 diabetes.
RECOMMENDATION:
This study design may serve as a model for the study of the effectiveness
and cost-effectiveness of nutrition care for other diseases and conditions.
ABSTRACT:
A 2year clinical study has been designed to test three hypotheses for
persons with type 2 diabetes treated in an ambulatory setting with either
basic nutrition care or care based on practice guidelines determined by
expert consensus. The hypotheses are that nutrition care based on practice
guidelines will significantly lower blood glucose levels, will significantly
improve abnormal lipid profiles, and will significantly control weight
in obese patients; in each case, the change is to be within three months,
with a requirement for stabilization or further improvement over the next
three months. The study will include 240 patients diagnosed with type
2 diabetes and free of diabetes complications (e.g., nephropathy), who
were recruited from ambulatory clinical sites in three states and randomly
assigned to either basic nutrition care or care based on the guidelines.
The patients will be between the ages of 40 and 70 years, must be able
to attend the clinics as required by the protocol, and be willing to follow
either the basic or practice guideline care regimen. Patients will be
evaluated at study enrollment, at three months, and at six months. Data
will be collected for biophysical measures (e.g., blood glucose, body
mass index), behavior/education (e.g., compliance, knowledge), and cost.
Records will be kept of adverse events (e.g., coma, infections). A cost
analysis of the two interventions will document the costs for labor, administrative
overhead, supplies, and medications related to direct service delivery
and outpatient treatment. Rigorous documentation of effects and careful
cost documentation will permit a cost-effectiveness analysis to be performed.
1 figure, 35 references.
242
TITLE:
Preventive Health Services for Medicare Beneficiaries: Policy and Research
Issues. Washington, DC: Office of Technology Assessment, United States
Congress. February 1990. 37 pp.
OBJECTIVE:
To examine the process that dictates the coverage and delivery of preventive
services for Medicare beneficiaries.
CATEGORY:
Policy/position statement.
CONCLUSION:
None.
RECOMMENDATION:
Consideration should be given to funding extended follow-up periods at
some of the sites for federal demonstration projects on the costs and
effectiveness of providing preventive health services under Medicare.
Effectiveness research should be targeted to services offering the potential
for large impacts on health status or health costs of the elderly.
ABSTRACT:
Vaccines for pneumococcal pneumonia and hepatitis B, screening, mammography,
and Pap smears are the only preventive services covered by Medicare. The
wisdom of excluding preventive services has been questioned by numerous
experts and interested groups. The authors point out that some procedures
performed for screening purposes (e.g., lower GI endoscopy) may be paid
by Medicare as diagnostic procedures, and tertiary preventive services
(e.g., hypertension control) may be reimbursable as therapeutic services.
In addition, Medicare beneficiaries enrolled in health maintenance organizations
or other competitive medical plans may receive extra preventive care.
The authors note several reasons why Medicare coverage of a preventive
service may not be enough to bring about appropriate use patterns; consumer,
physician, and service characteristics may be more important than out-of-pocket
costs. The current strategy for adding preventive services is ad hoc and
procedure-specific; formulation of a complete strategy requires choices
in the unit of payment (individual procedures versus a service package),
criteria to govern the coverage decision and standards for evidence (possible
criteria include effectiveness, cost-effectiveness, impact on Medicare
outlays, and net economic benefits), and locus of responsibility for coverage
decisions. The authors discuss several issues relating to the evaluation
of evidence on the cost-effectiveness of preventive services for the elderly
and note that the Health Care Financing Administration is supporting six
demonstration projects whose goals are to assess the costs and effectiveness
of providing health services under Medicare. They cite problems (e.g.,
design and funding) in the studies and predict that the evidence they
produce will be limited. Appendices A-D cover acknowledgments, Office
of Technology studies in preventive services for the elderly, Medicare
preventive services demonstration projects, and recommendations for periodic
health examinations in the elderly. 6 tables (1 in main text, 5 in appendices),
4 appendices, 101 references.
243
TITLE:
Preventive Services. United States Department of Health and Human Services,
Public Health Service, Health Care Financing Administration. In: State
Medicaid Manual. Part 4: Services. Transmittal No. 41. February 1989.
4 pp.
OBJECTIVE:
To provide guidelines on optional coverage of preventive services under
Medicaid.
CATEGORY:
Policy/position statement.
CONCLUSION:
Increased use of preventive services offers the potential for improving
individual health and reducing the cost of treating illness and injury.
RECOMMENDATION:
States should consider reviewing their Medicaid programs for ways to make
a wider range of preventive services available and accessible to their
Medicaid beneficiaries.
ABSTRACT:
In addition to including preventive care as part of other covered services,
each state may cover preventive care as a separate benefit under its Medicaid
program. For a Medicaid service to be covered, it must involve direct
patient care and be for the express purpose of diagnosing, treating, or
preventing (or minimizing the adverse effects of) illness, injury, or
other impairments to an individual's physical or mental health. Often,
a state may have a wide range of preventive services available, but the
services are fragmented among numerous agencies and programs in addition
to Medicaid. States interested in initiating or expanding a Medicaid preventive
care effort can take a two-pronged approach: (1) Medicaid funding of medically
oriented personal preventive services for which federal financial participation
is available under Title XIX; and (2) increased coordination between Medicaid
and other programs that fund or provide preventive care, including referral
to social and environmental programs and services. In evaluating amendments
to state plans for providing preventive services, the Health Care Financing
Administration requires that the proposed services be preventive and fit
within the basic Medicaid medical-remedial framework, be directed at the
patient, not be otherwise available without cost, not duplicate other
federally funded services, and not entail additional payment for a service
that is logically a part of otherwise covered services (e.g., a physician
providing preventive counseling). Regarding coordination with other programs,
the Medicaid agency can perform a valuable referral function and help
to supplement available preventive services by directing beneficiaries
to appropriate preventive care (e.g., examinations, immunization and treatment
services) available from other sources.
244
TITLE:
Public Health Focus: Physical Activity and the Prevention of Coronary
Heart Disease. Centers for Disease Control and Prevention. Morbidity
and Mortality Weekly Report (MMWR). 42(35): 669–672.
September 10, 1993.
OBJECTIVE:
To summarize information on the potential efficacy and cost benefit of
promoting physical activity as a way to prevent coronary heart disease.
CATEGORY:
Policy/position statement.
CONCLUSION:
Educating health professionals and lay persons to implement effective
ways of reducing risk factors for coronary heart disease could reduce
health care costs substantially.
RECOMMENDATION:
Sites that promote physical activity should emphasize participation in
a variety of self-directed, moderate-level physical activities with a
goal of 30 minutes of participation a day for 5 days a week.
ABSTRACT:
Coronary heart disease is the leading cause of mortality in the United
States; each year 1.5 million people are diagnosed with this disorder,
whose direct and indirect heath care costs are estimated at $47 billion.
A 1987 review of 43 epidemiologic studies concluded that moderate to vigorous
physical activity reduced coronary heart disease. The risk for coronary
heart disease was almost doubled for persons who were physically inactive.
Based on 1989 mortality estimates for coronary heart disease, the extrapolated
cost of physical inactivity was $5.7 billion, with elevated serum cholesterol
the only risk factor for coronary heart disease having a higher estimated
cost. In an analysis using hypothetical cohorts over a 30-year period,
physical activity was associated with 78 fewer coronary heart disease
events and 1,138 quality-adjusted life-years gained. For each quality-adjusted
life-year gained, direct cost equals $1,395 and total costs, $11,313.
Worksite-based physical activity programs have been estimated to cost
employers $100 to $400 per employee per year, but they return an estimated
$513 per employee per year. A Canadian intervention program reduced medical
claims $6.85 per year for each dollar invested. Annually, in the United
States, 20,000 fewer people would die if half the persons with no leisure-time
physical activity engaged in moderate physical activity two to three times
per week. Physical activity may prevent coronary heart disease by improving
weight control, enhancing glucose tolerance and insulin sensitivity, reducing
blood pressure, improving coronary artery blood flow, and augmenting high-density
lipoprotein levels. Educating health professionals and lay persons to
implement effective ways to reduce risk factors for coronary heart disease
could result in substantially reduced health care costs. In addition to
worksite programs, physical activity programs have been promoted in the
schools, community, physician offices, health clinics, homes, and neighborhoods.
2 tables, 16references.
245
TITLE:
Public Health Focus: Prevention of Blind-ness Associated with Retinopathy.
Division of Diabetes Translation, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease Control and Prevention.
Morbidity and Mortality Weekly Report (MMWR). 42(10): 191–195.
March 19, 1993.
OBJECTIVE:
To summarize information on the efficacy and cost-effectiveness of screening
for retinopathy.
CATEGORY:
Policy/position statement.
CONCLUSION:
(from editorial note) Screening for retinopathy is effective for preventing
blindness and is cost effective.
RECOMMENDATION:
(from editorial note) Improvement must be made in the timeliness of screening,
case-finding, and entry into the health care system of persons with diabetes.
All persons with diabetes (except those with type 1 diabetes for less
than 5 years) should receive an annual dilated-eye examination by a trained
provider with appropriate referral and treatment.
ABSTRACT:
Studies of the efficacy and cost-effectiveness of screening for retinopathy
are reviewed. More than 90 percent of persons with type 1 diabetes have
some retinopathy 15 years after diagnosis; 90 percent of persons with
type 2 diabetes who are treated with insulin have some retinopathy 25
years after diagnosis. Among type 2 patients not treated with insulin,
more than 60 percent have some retinopathy after 20 years. Prospective
clinical trials have shown that laser photocoagulation therapy is effective
in reducing the risk of visual impairment. Panretinal laser photocoagulation
can reduce the risk of severe visual loss by at least 60 percent in some
patients with diabetes. An annual eye examination can identify retinopathy
early and permit timely treatment to prevent loss of vision and possible
blindness; in a retinal study, however, half of diabetes patients had
not had a dilated-eye examination in the preceding year. Economic evaluations
indicate that screening for retinopathy costs less than the cost of 1
person-year of blindness. A study by Dasbach et al. (1991) showed that
biannual and annual screening programs for persons with type 1 and type
2 diabetes were cost effective. A study by Javitt et al. (1990) evaluated
the cost-effectiveness of different screening protocols for retinopathy
in patients with type 1 diabetes; the various strategies were estimated
to save $62 million to $109 million and 71,000 to 85,000 sight years annually
in the United States. 2 figures, 1 table, 14 references.
246
TITLE:
Rediagnosing Health Care: Providers' Perspectives. Shortridge, C.L. Diabetes
Care. 17(3): 248250. March 1994.
OBJECTIVE:
To provide an overview of the Health Security Act unveiled by President
Clinton in October 1993 and to discuss the potential health care implications
of this plan should it be enacted.
CATEGORY:
Policy/position statement.
CONCLUSION:
The American Diabetes Association supports health care reform, but the
specifics of the Health Security Act give concern to many physicians who
treat patients with diabetes.
RECOMMENDATION:
As this and other health care plans are circulated through Congress, concerns
raised by the medical community (e.g., ease of referral to specialists
in the treatment of diabetes, effective preventive services for people
with diabetes) must be considered.
ABSTRACT:
If passed, President Clinton's 1993 Health Security Act would create a
national managed competition system with health alliances, which would
be similar to health maintenance organizations and preferred provider
organizations. Some physicians fear that this system will hurt private
practice, restrict access to specialists, and impair freedom of choice.
The Health Security Act establishes a seven member National Health Board
that would oversee the health care system, which would be composed of
regional or corporate health alliances or state run, single-payer systems.
Regardless of which system a state chooses, a comprehensive benefits package
will be offered. The American Diabetes Association is committed to ensuring
that the plan's basic benefits package includes access to appropriate
diabetes treatment and management. Physicians in a health alliance will
be paid by the alliance, and those in a single-payer system will be reimbursed
by the state. Provider fees will be set by the alliance or by the state.
Physicians may choose to join the health alliance or single-payer system
in their state or remain outside the system in private practice. The only
way patients can access a provider in private practice, however, is to
pay for the visit themselves. The plan will establish programs to retrain
some specialists as primary care physicians. The plan will also guarantee
that 55 percent of medical students enter residencies in family medicine,
general internal medicine, general pediatrics, or obstetrics and gynecology.
To further deter specialization, the plan will determine the number of
specialty slots nationwide available for enrollment in medical education
programs.
247
TITLE:
Resource Manual to Help Your Program Meet the National Standards. Teza,
S.L.; DeVito, A.V. II; Hiss, R.G. Diabetes Educator. 13
Supplement: 210–228.
May 1987.
OBJECTIVE:
To provide advice on developing or improving diabetes education programs;
to give specific suggestions on ways to meet the National Standards for
Diabetes Patient Education Programs.
CATEGORY:
Policy/position statement.
CONCLUSION:
Specific suggestions are provided for establishing, organizing, implementing,
and evaluating education programs for patients with diabetes.
RECOMMENDATION:
These program suggestions should be considered by diabetes educators in
developing and evaluating their patient programs.
ABSTRACT:
The authors first discuss needs assessment standards, which involve evaluating
the need for diabetes education in the area served by a given institution
and the educational needs of persons with diabetes. The planning phase
of a diabetes education program is then detailed, including methods of
establishing policy, the development and role of an advisory committee,
and the steps involved in actual program planning. Program management
is then discussed, including the role of the program coordinator, organizational
relationships, and budgeting. The fourth section examines communication/coordination,
the use of physician liaisons, educational teams, and education records
and provides sample education records. The fifth through tenth sections
deal with patient access to teaching, content/curriculum, instructors,
follow-up, evaluation, and documentation. A glossary of terminology and
a collection of abstracts relating to diabetes education programs are
included. Also included are the National Standards for Diabetes Patient
Education Programs, which were developed under the aegis of the National
Diabetes Advisory Board and have been endorsed by the diabetes community.
6 figures, 16 tables, 1 glossary.
248
TITLE:
Screening for Diabetes Mellitus. U.S. Preventive Services Task Force.
In: Guide to Clinical Preventive Services: An Assessment of the Effectiveness
of 169 Interventions. Baltimore: Williams & Wilkins. 1989. pp. 95–103.
OBJECTIVE:
To assess the appropriateness of screening for diabetes mellitus in the
U.S. population.
CATEGORY:
Policy/position statement.
CONCLUSION:
Screening for diabetes mellitus has not been proven sufficiently beneficial
in nonpregnant, asymptomatic individuals to warrant widespread use.
RECOMMENDATION:
An oral glucose tolerance test is recommended for pregnant women between
gestational weeks 24 and 28, but routine plasma or urine glucose screening
in other asymptomatic persons is not recommended except possibly for people
at high risk for diabetes.
ABSTRACT:
The authors discussed screening for diabetes mellitus in the population
at large. As there are large intra- and interindividual variations in
glucose measurements in healthy individuals and those with impaired glucose
tolerance or diabetes, complex criteria involving multiple measurements
are needed for a definitive diagnosis. Fasting blood glucose is an accurate
test, but fasting is inconvenient, and, in some cases, sensitivity has
been poor. Postprandial blood glucose is more convenient, but the time
limitations for collecting blood makes it difficult to use for screening.
The oral glucose tolerance test (GTT) is expensive and inconvenient because
of the requirement for multiple venipunctures over several hours. A half-dose
oral GTT for pregnant women has 83 percent of the sensitivity and 87 percent
of the specificity of the full-dose GTT; for every true positive case
of gestational diabetes identified, 5 false positives are found. Urine
glucose testing is considered unreliable with a sensitivity of less than
30 percent. Evidence is conflicting about the benefit of early detection
and treatment impaired glucose tolerance; most people do not develop diabetes
even without treatment. Data on the effect of early glycemia regulation
on the subsequent development and progression of complications from diabetes
are also conflicting. Studies have shown benefit to mother and child of
glycemic control during pregnancy, although the influences of good prenatal
care on outcome could not be assessed. An oral GTT is recommended for
pregnant women between gestational weeks 24 and 28, but routine plasma
or urine glucose screening in other asymptomatic persons is not recommended,
except possibly for people at high risk for diabetes. 79 references.
249
TITLE:
Source Book of Health Insurance Data 1991. Health Insurance Association
of America. Washington, DC. 1991. 135 pp.
OBJECTIVE:
To provide a basic reference tool for private health insurance in the
United States.
CATEGORY:
Policy/position statement.
CONCLUSION:
None.
RECOMMENDATION:
None.
ABSTRACT:
The authors describe the role and function of health insurance (chapter
1) and review the private health insurance industry (chapter 2). Succeeding
chapters discuss public health coverage — expenditures and enrollment;
medical care costs; health services, resources, and utilization; and disability,
morbidity, and mortality. Brief sections cover "health and health
care acronyms" and "historical facts." An extensive glossary
is included. The report contains tables on a wide variety of topics, including
coverage, premiums, health maintenance organization enrollment, Medicare
enrollment, national health expenditures, hospital utilization, disability
days, and many others. Data in the book were obtained from reports of
insurance companies, government agencies, hospital and medical associations,
and other health insurance plans. The book has been published annually
by the Health Insurance Association of America since 1960. 67 tables.
250
TITLE:
Third Party Coverage for Diabetes Education Program. Schwartz, R.; Zaremba
M.; Ra, K. Quarterly Review Bulletin. 11(7): 213–217.
July 1985.
OBJECTIVE:
To review the Ambulatory Diabetes Education and Follow-up Program in Maine
and its efforts to acquire third party reimbursement.
CATEGORY:
Policy/position statement.
CONCLUSION:
The Maine Diabetes Control Project has successfully obtained third party
reimbursement for a diabetes education program, first as a demonstration
project, then on the basis of a study that revealed its economic benefit.
RECOMMENDATION:
Health education programs seeking reimbursement are encouraged to keep
up with existing literature and Medicare and Medicaid regulations, ensure
representation from third party payers, and prepare a cost-benefit analysis.
ABSTRACT:
Under an agreement with the Centers for Disease Control, Maine's Department
of Human Services developed the Ambulatory Diabetes Education and Follow-up
Program by working with area physicians to identify individuals with diabetes,
interviewing the patients to assess their level of knowledge and attitudes
about diabetes, and enrolling individuals and family/friends into group
education classes and individual diet counseling. The curriculum (five
classes plus a one-to-one dietary counseling session) covered an introduction
to diabetes, testing and hyperglycemia, meal planning, medications and
hypoglycemia, and "general factors" such as foot care, smoking,
and publications and associations. In 1980, major third party payers agreed
to reimburse hospitals or rural health centers in the state for this program
if participants were referred by a physician, had an individualized education
plan, had records maintained for them, and if the program met state guidelines.
A follow-up study for January 1981 through June 1982 found that the number
of hospitalizations and length of stay were both reduced 32.2 percent,
with a gross savings of $359,835. Participation in the program cost $150
per participant and resulted in a net savings of $293 per patient. Blue
Cross-Blue Shield of Maine, Medicare, and Medicaid have continued to reimburse
the program, which the parent Diabetes Control Project oversees to ensure
its quality and to keep insurers informed of institutions that are participating.
The authors suggest that those seeking third party coverage become familiar
with existing literature and with Medicare and Medicaid regulations, solicit
representation from third party payers at the project's beginning, prepare
a cost-benefit analysis, form a committee of various entities (e.g., Blue
Cross-Blue Shield, the hospital association) that might endorse the project's
efforts to get reimbursement, and gain and maintain physician support.
2 figures.
251
TITLE:
Third Party Reimbursement for Outpatient Diabetes Education and Counseling.
American Diabetes Association. Diabetes Care. 13 (Supplement 1):
S36. January 1990.
OBJECTIVE:
To articulate the position of the American Diabetes Association on reimbursement
for outpatient education programs for patients with diabetes. (Note: This
position statement was superseded by "Third Party Reimbursement for
Diabetes Care, Self-Management Education, and Supplies." Diabetes
Care. 19 (Supplement 1): S48. January 1996.)
CATEGORY:
Policy/position statement.
CONCLUSION:
Not making outpatient education a covered benefit is a major barrier to
its availability and accessibility.
RECOMMENDATION:
The American Diabetes Association strongly supports and encourages adequate
reimbursement and payment for those outpatient education services for
patients with diabetes that meet accepted standards.
ABSTRACT:
Complications for patients with diabetes cost about $20 billion in 1987.
Many studies have shown that education and self-management programs reduce
costs of diabetes. Continuing patient education for self-management is
integral to diabetes treatment, and all people with diabetes should have
access to affordable patient education. National standards and a quality
assurance program are already in place. The major barrier to patient education
services is the lack of reimbursement by insurers and health care financing
plans. 10 references.
252
TITLE:
Worksheet to Estimate Program Costs and Savings. Hunt, C. Diabetes
Educator. 16(4): 282283. July-August 1990.
OBJECTIVE:
To provide a worksheet that clinicians can use to estimate program costs
and net cost savings for diabetes outpatient education programs.
CATEGORY:
Policy/position statement.
CONCLUSION:
None.
RECOMMENDATION:
None.
ABSTRACT:
A worksheet used by Pennsylvania diabetes outpatient education programs
to assist them in their dialogue with third party payers is presented.
According to Barbara Bodnar, diabetes nurse consultant with the Pennsylvania
Department of Health, pilot studies have documented a one-third reduction
in inpatient hospital usage attributable to diabetes outpatient education
programs. The worksheet has three distinct sections: inpatient costs,
program costs, and net cost savings (estimated). Users of this worksheet
simply input numerical data as outlined in the instructions. Upon reaching
the end of the worksheet, users will have an estimate of the net savings
to their hospital/clinic from the diabetes outpatient education program.
A 30 percent figure is used in the worksheet for the reduction in hospital
costs from diabetes patient education.
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