Building the Business Case for DSMES
Diabetes is a significant cause of serious health complications and early death. Currently, diabetes affects 37.3 million Americans, or 10.5% of the US population.6
As of 2017, the financial impact of diabetes was estimated at $327 billion, including direct financial costs and indirect effects on health resources and productivity.9 These costs are expected to continue to increase as diabetes rates continue to climb.40
It is critically important to provide people with the tools and skills to self-manage diabetes.43 This is the purpose of diabetes self-management education and support (DSMES) services. As discussed in the Overcoming Barriers to Referral and Treatment section of this toolkit, less than 5% of Medicare beneficiaries with diabetes and 6.8% of privately insured people with diabetes participate in a DSMES service within the first year of diagnosis.2,3
Identifying and addressing barriers is important for the sustainability of DSMES services, including:
- Programmatic barriers to starting or sustaining DSMES services.
- Health care provider barriers to referral.
- Barriers to individual access and participation.
Although DSMES services have not always been able to cover their costs and expand, that trend is changing. According to the 2017 National Practice Survey, 20% of DSMES services were at least revenue- or cost-neutral, 9% ran at a profit, and 21% did not charge for services. Although 15% ran at a loss in 2017, this percentage represents a steady decline from the high of 43% running at a loss in 2007.42
Making a business case for DSMES services is critical to long-term success and sustainability. The primary business case rests on the fact that DSMES services are associated with “increased use of primary and preventive services and lower use of acute, inpatient hospital services.”43 Research shows that when diabetes care and education specialists and physicians collaborate, “positive clinical quality and cost savings” result.44
Participation in DSMES services can improve hemoglobin A1C by 0.6%—as much as many medications and without side effects.46 One study found a 34% lower hospitalization rate for people with diabetes who had at least one educational visit compared to people with diabetes who had none. A cost analysis of disease management services combined with diabetes education reported a return on investment of $4.34:1.45 In a 3-year retrospective claims analysis of 250,000 Medicare beneficiaries, those who participated in a DSMES service demonstrated an average cost savings of $135 per month.43
Because health care costs are lower for people with diabetes who attend at least one DSMES session, the benefits of DSMES services outweigh the costs of providing the services.44
People who participate in DSMES are more likely to follow best-practice treatment recommendations and have lower claims costs. Increasing referral rates to DSMES (especially among low-referring physicians) and increasing underserved populations’ access to DSMES are promising strategies for increasing health care quality and reducing costs.43
Making the Case for DSMES to Employers and Insurers
Employers and insurers benefit from DSMES through improved employee productivity and reduced health care costs. State health departments can work with their diabetes councils or partner networks to inform and educate employers and insurers on the benefits of DSMES services and encourage coverage.
Employers are eager to hear that insurers have strategies to address the rising costs of diabetes. Encourage employers to talk with their insurance carriers about adding DSMES services as part of the employee health benefits package.
Value of Diabetes Care and Education Specialists
Diabetes care and education specialists (DCESs) are critically important to the provision of DSMES services.42 They have the knowledge and skills necessary to educate people with diabetes about diabetes and its complications.42 In addition, DCESs possess the communication and support skills needed to deliver comprehensive yet individualized diabetes education that helps people manage daily challenges while working toward long-term behavior change.
Studies indicate that, when provided by DCESs in accredited or recognized programs, DSMES “is both clinically beneficial and cost-effective,” particularly with repeat educational encounters.44 In other words, more time spent with DCESs leads to better outcomes.43,47,48
People with diabetes who attend multiple DSMES sessions led by a DCES are more likely to take medications as prescribed and receive recommended care. They also have lower health care costs than people with diabetes who do not receive DSMES.
Unfortunately, even though many third-party payers cover DSMES in part or in full,43 participation rates in recognized or accredited services remain low. Low participation may be because eligible people with diabetes are not receiving referrals to DSMES services or because of barriers to participation. In this context, DCESs serve a doubly important role, not only in providing DSMES services but in educating insurers, physicians, health care providers, and people with diabetes and their families about the importance and effectiveness of DSMES referrals and participation. See the Marketing and Promotion section for resources to help DCESs talk about the benefits of DSMES services.
The resources below provide more information on the value of DCESs:
Find resources to show DSMES is proven to improve health and behavioral outcomes and is a cost-effective way to increase health care quality while decreasing health care costs.
Learn how DSMES can decrease health care costs by lowering hospital admissions and readmissions, reducing risks of complications, and improving long-term behavioral change.
Learn how DSMES aligns with national quality measures, including those for patient-centered medical homes and accountable care organizations.
Learn how business plans are useful tools to start, maintain, and ensure sustainability of DSMES services.