On-Site Educators Lead to Better Type 2 Outcomes
Thus far, she has scheduled initial visits for 90 minutes and return visits for 45 minutes. Her approach exemplifies the trend in diabetes education, away from didactic programs to sessions aimed at getting patients engaged in setting goals, changing behaviors, and solving problems.
Most patients decide to return for 2–4 group sessions per year—most of which fall within Medicare's allowed coverage of 10 hours in the initial year (including 9 hours of group education) and 2 hours each subsequent year. The physician is responsible for maintaining the plan of care in the patient's medical record.
It will become easier for physicians to get ADA certification for education programs as the association becomes more flexible. For example, the ADA is now allowing programs to apply for “expansion site” recognition, an arrangement that could apply to a partnership between a primary care practice and a hospital, Dr. Siminerio said.
Reimbursement Issues Pose Challenges
The finances of the program are a work in progress—and, not surprisingly, reimbursement is the most challenging issue the project leaders face. “Insurer issues,” as Ms. Emerson calls them, are at the forefront.
“Many insurers were concerned that DSME in primary care was being provided by the physicians and/or staff as opposed to an ADA-recognized program,” she said at the meeting. “They just thought it was a physician-driven program and they weren't going to pay for it, no matter how we explained it.”
In the first quarter of 2006, the three practices that had begun billing by that point together billed for $31,560; this covered 109 encounters (61 group sessions and 48 individual) in 19 days, with 70 different patients and 20 insurance plans. Community Medicine's reimbursement: $5,907. Of this, $4,197 went to the University of Pittsburgh's Diabetes Institute.
“We were actually quite pleased with how much we were able to charge, and we weren't displeased with the reimbursement, though we need to recover more to make the program sustainable,” Ms. Emerson said. Recouping even 50% of the charges would make a difference, she said.
Dr. Solano, however, thinks it's going to take more to be truly “cost-effective for primary care.”
“The question is, how can you get it funded by insurers—really, fully underwritten by insurers—but have diabetes educators do true education and not just the 'disease management' that insurers [have touted]?” said the internist, who, in addition to practicing, serves as medical director of the's Center for Quality Improvement and Innovation at the University of Pittsburgh Medical Center.
“Even with better reimbursement levels, the amount of money people get paid certainly is not going to support their salary,” he said.
A model that builds on the CDE model and uses a practice-based educator for a broader swath of education—asthma education and depression education, for example, in addition to the diabetes education—may be more cost effective, he said.
Dr. Siminerio, however, expects reimbursement for diabetes education to increase as insurers realize that CDEs can deliver services in physicians' offices effectively—and particularly, as insurers see outcomes data from the sources such as the Community Medicine practices. “At this point, it's such a new model,” she said.
