August 2-6, 2011; Las Vegas, NV Commentary – Reimbursement and Health Policy – Draft

Executive Highlights

While there was some disagreement on the appropriateness of pay-for-performance models, there was general consensus that educators will have to further demonstrate (and quantify) their value going forward to become recognized as an integral part of patient care. Providing context for the adoption of pay-for-performance models, David Aron, MD, MS (Case Western Reserve University, Cleveland, OH) emphasized that the current methods of payment do not properly incentivize physicians to provide the best care. He stated that while salaries encourage people to do as little as possible for as few people as possible, capitation incentivizes physicians to do as little as possible for as many people as possible, and fee-for-service (the predominant payment method) encourages healthcare providers to do as much as possible but only for those who can pay. Denise Bockwoldt, MS, RN, FNP, BC-ADM (Advocate South Suburban Hospital, Chicago, IL) expressed similar sentiments during her presentation; however, Dr. Aron and Ms. Bockwoldt disagreed on the prospect of pay-for-performance models. Dr. Aron explained that pay-for-performance models are still fundamentally motivated by greed and argued for an increased emphasis on public reporting to encourage physicians to provide better care without attaching financial incentives. In contrast, Ms. Bockwoldt believed that pay-for-performance would be able to drive down healthcare costs while improving the quality of care, citing her own experience at the Advocate South Suburban Hospital as an example.

In addition, speakers were optimistic that healthcare reform would improve both access to and quality of patient care. During the conference’s opening general session, panelists reviewed and discussed the implications of the Affordable Care Act (ACA), noting that it would not only expand insurance coverage for 30 million people, but also emphasize prevention and education. For example, the ACA gives CMS the authority to implement new preventative services – with some limitations – without congressional approval. In addition, Patty Telgener, RN, MBA (VP of Reimbursement, Emerson Consultants) noted that effective 2010, uninsured people with diabetes are now able to access insurance through high-risk pools specifically created to make insurance available until the provisions banning discrimination are fully in place in 2014. Insurers are also no longer able to exclude children with diabetes from their parents’ insurance. Meanwhile, Palo Alto Medical Foundation (PAMF) Chief Innovation and Technology Officer Paul Tang, MD (PAMF, Palo Alto, CA) expressed confidence that the HITECH provision included in the American Recovery and Reinvestment Act (ARRA) of 2009, which mandates the adoption of electronic health records (EHRs) by 2014, would ultimately help to increase patient learning, empowerment, and outcomes by relaying more information back to patients.

Reimbursement and Health Policy

General Session

HEALTHCARE REFORM APPLIED TO DIFFERENT SETTINGS: A PANEL DISCUSSION

Susan Dentzer (Editor in Chief of Health Affairs, Washington, DC), Barry Straube, MD (Centers for Medicare and Medicaid Services, Washington, DC), Susan Voss (National Association of Insurance Commissioners, Des Moines, Iowa), Paul Keckley, PhD (Deloitte Center for Health Solutions, Washington, DC), and Donna Tomky, MSN, RN, C-NP, FAADE (AADE President, ABQ Health Partners, Albuquerque, NM)

The packed opening general session of AADE 2011 began with a moving rendition of the national anthem by Miss Junior Teen Nevada Fallon Smythe. After an introductory video, AADE president Donna Tomky took the stage and addressed the theme of this year’s meeting – “Advancing Minds That Care.” She highlighted how special diabetes educators were given their commitment to caring for the entirety of their patients and the necessity for all diabetes educators to continue advancing their skill set by attending these meetings in order to provide even greater care for their patients. Following these opening remarks, Editor in Chief of Health Affairs Susan Dentzer led an interesting discussion on the potential impacts of the healthcare reform and recent budget deficit legislation on diabetes educators, diabetes care, and diabetes prevention. With panel members representing CMS, private insurance companies, and diabetes educators, we found the session to be quite informative on the future directions of diabetes care in the US. We found the messages conveyed by the panel to be optimistic, with seemingly all the panel members agreeing that the Affordable Care Act will provide increased opportunities and tools to tackle the diabetes epidemic – although a number of hurdles and questions remain.

Panel Discussion:

Ms. Susan Dentzer: It is hard to think of another disease in which what you all do as diabetes educators is more important for achieving better patient outcomes. In an article I read this morning, I found out that Francis Collins (Director of the NIH) had his complete genotype tested, and he discovered that he was at high risk of developing type 2 diabetes. It was not until then that he became motivated to change his lifestyle. However, most of us don’t have $8,000 to spend on genotype testing. Yet, we have you. We know that patient outcomes would be far worse if all of you were not part of their lives.

In today’s panel discussion, we will be discussing healthcare reform and what it means for you. The Affordable Care Act (ACA) was passed in 2010. We can view this as the first wave of healthcare reform. Now that federal budget deficit reduction legislation has been passed, there will also be a second wave of healthcare reform. This will likely entail changes to federally funded health programs, including Medicare and Medicaid. A bipartisan panel will convene in November and make recommendations on how to create more than a $1 trillion of spending cuts in the coming years. In the news today, it was reported that Medicare and Medicaid spending growing at annual rates of 10%. For this year, spending between these programs is expected to reach $1 trillion. This second reform wave will try to reign in the costs of these programs. There will likely be as many changes in this wave for patients as there were in the first wave.

Let’s briefly review the ACA. First of all, the ACA calls for insurance coverage expansion. 30 million or more newly insured patients will begin to be covered by Medicare or Medicaid as of 2014. We know this will bring millions of people with diabetes your way. There are also a number of different payment and delivery system reforms. There will be accountable care organizations and medical homes, which may represent new ways of organizing and paying for healthcare to achieve better health, better healthcare, and lower costs. The ACA also puts a key focus on prevention. Prevention and education will form important aspects of the essential benefits package that must be offered by insurance plans listed in the health insurance exchanges. There will be a prevention trust fund and the Diabetes Prevention Program, an evidence based lifestyle intervention program aimed at individuals at high risk for developing type 2 diabetes. As this program rolls out, it will provide opportunities for collaboration between government, local communities, and providers to reduce the incidence of type 2 diabetes going forward. All of these changes create new opportunities for diabetes educators.

What changes will occur in wave number two? We don’t know yet. It is hard to believe that they wouldn’t make changes that won’t bear on what diabetes educators do in some way. At least $1 in every $4 or maybe $3 that the government spends on healthcare is spent on diabetes or diabetes related conditions, and this could be even higher if heart disease was counted. So with diabetes as big as a contributor as it currently is, wave number two will likely have some impact on CDEs.

To start of the discussion, let’s start with you Dr. Straube? What do you think are the major takeaways from the ACA for diabetes educators?

Dr. Barry Straube: I think it is important for everyone to try to spend some time learning about the legislation. You are not completely isolated from what will eventually get implemented. Learn about the themes and issue, get involved with AADE, and lobby for the changes that are important for you. After reading through the 906 page legislation five times now, I am struck by how infrequently diabetes is mentioned given the size of the problem. The good news is that in just about each paragraph that discusses wellness, prevention, and chronic disease management, there is a focus on diabetes. You need to find out which sections in the ACA focus on diabetes. Section 10407 is the Better Diabetes Care section. This section incorporates the Catalysis for Better Diabetes Care Act, which aims to collect data about key diabetes statistics and to create a national report card on how we’re doing with diabetes every two years— the format and content for this has not yet been defined. Diabetes educators can play a key role in collecting this data. The section also stresses the need for better coordination and alignment between difference centers of excellence for diabetes, mental health, kidney disease, etc. in order to provide better, more comprehensive care for patients. Then there is the National Diabetes Prevention Program. I wont go into that in great detail.

Ms. Dentzer: What is the top issue on your mind Ms. Voss?

Ms. Susan Voss: As you know, in the insurance exchanges, the carriers are required to have a certain type of product available to consumers. One big question that remains is what providers will be covered under these insurance plans? We have had a lot of providers coming to us asking whether their services will be covered under the new plans.

Ms. Dentzer: The essential benefits package is set by the Secretary of Health and Human Services. What do we know about whether diabetes education and self-management training will be included in the essential benefits package?

Ms. Voss: Because prevention and wellness are discussed on so many levels in the ACA, I would be shocked if it was not included in some shape or form. A lot of data have recognized the importance of diabetes education.

Ms. Dentzer: Dr. Keckley, can you comment on what you think is important regarding the cost of diabetes care, cost of prevention, and the return on these investments?

Dr. Paul Keckley: In addition to the 900-page legislation, there are about 60,000 pages of guidance as well. So, to this group, one important aspect of healthcare reform will be how the law is implemented with all of this guidance, especially given that it will likely happen over the course of five election cycles. Secondly, how do we now adjust the ACA following the deficit reduction legislation? There is nothing in this latter legislation that prevents the bipartisan committee from revisiting and changing aspects of the ACA. A third challenge is that politics in Washington usually pander to particular guilds and to fear. This is the third time I’ve been in this hotel in the past 45 days…each for a different group representing a different guild. We have an amazing system in which everyone defaults to their own guild and always asks the question: “what’s in it for them?” A question that I have is whether all of this new legislation will change behavior of people with chronic disease over the long-term. Will it only improve the health of people who are already inclined to eat better and exercise? Will it have any effect on people that need to change their behavior the most? How do you really measure the change based on these programs? If I receive a benefit to workout at the YMCA, and I am already a member, is that a true reflection of the net impact of the program? One last concern I have is in regard to the type of incentives we use to promote healthier behavior. I believe we have to use sticks and not carrots to award appropriate behavior and to help consumers more aggressively pursue improvements in their health.

Ms. Dentzer: What sticks do you recommend?

Dr. Keckley: From the studies that we have done, we have found that fear of consequences changes behavior. Fear of consequences is complicated. Sometimes the consequence can be money or the loss of something precious (such as a family member or friend). The science of the stick is still a work in progress. Sticks and carrots for diabetes are very different from those in other diseases such as cancer. We need to figure out what model produces the optimal results for what intuitively seems like the right thing to do. That way, we won’t have to defend the return on investment for diabetes education and a variety of other services constantly.

Ms. Dentzer: Ms. Tomky, let’s turn to you. What do you think are the biggest opportunities for diabetes educators in this environment?

Ms. Donna Tomky: Prevention is huge, whether it is fist line prevention of diabetes, secondary prevention of complications, or tertiary prevention of hospitalizations and so forth. We operate in a “sick care” healthcare system rather than a preventative one. There is no continuum of care. There are notable limitations on reimbursement for diabetes education that prevent such a continuum of care for people with diabetes. Yet, we know diabetes education has benefits. A recent research project conducted by AADE showed that diabetes education can improve metabolic outcomes, lower hospitalization rates, and lower costs. So we know it can work, and it will probably work much better on a continual basis.

Q: Dr. Straube, coming back to you. You know full well what the cost of diabetes is and what it is going to look like going forward. Because costs are so staggeringly high, why do you think it is so hard for us to wrap our minds around prevention? One argument is that all the benefits might go to people who would be healthy anyways. But at the margin, it seems like a lot of people could benefit from diabetes prevention education.

Dr. Straube: This is a complicated question. It is important to realize that in 1965 when Medicare was founded, there were zero preventative services in the program. It wasn’t until the late 1980s that such services began to be added by Congress. In order for such services to be added, Congress must pass legislation. So there are some statutory limitations to implementing prevention policies. However, this will change with the ACA. The ACA gives CMS the authority to implement new preventative services without Congressional approval—with some limitations. Simultaneously, we have had some fantastic political appointees at CMS. They have between a year and three years to implement what they want to do, but they get to pick their priorities. Prevention has not hit the political screen as something important yet. In the private sector, medical directors don’t want to deal with prevention because the effects are observed 10-30 years down the line. They do not get good return on investment right now. I think that this is going into the federal side to some extent. The ACA is making some attempt to changes this, however, and so has the Obama administration.

Dr. Keckley, I understand you focus on the stick. What I have learned is that while you do have to use the stick, the carrot has to be there too. You have to achieve a balance, and if you don’t people will dig their heels in.

Ms. Dentzer: Let’s talk about the new organizations that are coming out of ACA. There will be advanced primary care practices, medical homes, and accountable care organizations. As these organizations will have different focuses and will be paid differently, will there be more resources dedicated to diabetes education, self-management training, and prevention?

Dr. Keckley: It is hard to know. If you look at the reaction to the guidance released by the ACO on March 31, 2011, it has been tepid at best. We will wait and see. The fact that glycemic control is an important risk factor for so many medical conditions that Medicare reimburses for that can be reduced will be the link that is made. So I am pretty optimistic. I think the data shows that 9 out of 15 admissions in an acute setting relate to one of six chronic conditions left unmanaged. It has also been shown that a coaching model that carried out overtime can be effective in the Medicare setting. The complication is that in the commercial setting, an employer may not benefit directly from five years of diabetes education. By the time you are 40, you will have changed your job on average 5.4 times. However, I think if we shift more to a model of individual product than a group product, it will force people to pay more attention to their health and diabetes education will grow. Right now, I think estimates suggest employers are paying on average $30 per employee per month related to diabetes education, smoking cessation—some as little as $10. We think the market could be as much as $300 for a set of preventative services. We think this will occur if policies sponsored by employers are individual policies and not group policies. Employers will step in with the services necessary to modify behaviors. We think it’s a growth market, but there are just a few factors that we have to get through first.

Ms. Dentzer: Is there going to be less money for diabetes education? For strip supplies?

Ms. Voss: I don’t think so. The proof is in the pudding. The laws say you can’t use a stick, you have to treat everyone the same. The insurance industry is saying that if we have to spend 80% on every dollar on care, prevention, and wellness, we have to make sure people are doing what they are supposed to be doing. We will want to step in to do more to enforce adherence. This is an area for the insurance industry to really step in to promote diabetes education.

Ms. Dentzer: Ms. Tomky, how does the AADE feel about the use of sticks versus carrots?

Ms. Tomky: CDEs are very skilled in behavior change. One intervention does not work for everybody. That is what we are trying to understand in our own interventions and studies. I know that we as diabetes educators have to walk the walk. We have to do what we way ourselves. We have to be role models. We need to also have improved coordination of care as well. We will have to educate healthcare professionals about prevention and best practices. We deal with diabetes everyday, so who better. We need to find the right intervention for the right people at the right time.

Ms. Dentzer: Another big question facing the healthcare industry in the healthcare work force. Are there enough physicians, nurses, etc.? Are there enough CDEs in the right parts of the country? How do we allocate the workforce to meet demands in different areas of the country?

Dr. Straube: People are generally familiar with Titles I, II, and III of the ACA. However, Title V discusses improvements in the healthcare work force. There is an incredible amount of focus on training more people, especially in ancillary services—such as diabetes education. There is additionally a call for the gathering of more evidence on how the health care work force affects the clinical world, including centers of excellence and how they should be defined. There is a focus on community-based interventions. Diabetes educators are already dong that. We are seeing a number of community-based programs trying to expand diabetes education out of the traditional settings.

Ms. Dentzer: In rural parts of Iowa, can you find sufficient numbers of CDEs?

Ms. Voss: We have some counties that have only one physician. Physicians tend to end up in urban areas. Insurance carriers have to provide incentives to providers in rural areas to make sure these services are available.

Ms. Tomky: It takes a village to care for people with diabetes and to prevent the condition. We need to have more diabetes education. Every healthcare professional needs to know about diabetes education. It is a real hindrance to have to travel 100 miles to get to your nearest diabetes educator. AADE is taking this on as an initiative to really change the system.

Ms. Dentzer: We know from the diabetes prevention program that five to seven percent weight loss can have a profound effect on preventing progression to diabetes. Whether it is educating people or behavior modification, sticks or carrots, when people get an intensive set of interventions, we do find success. How come we don’t pay for any of this with Medicare?

Dr. Straube: There are no benefits now, but there could be several shortly. With ACA, an annual wellness exam is now mandated to be paid for by Medicare. While it is not specific diabetes prevention, these visits could certainly address the topic. Some think that all visits should include prediabetes care in addition to other services. Providers have been so overwhelmed with all the other tasks that are required for certain visits, however. The ultimate reason there is nothing now is economics. There is a certain amount of skepticism in the government and private sector about how effective weight loss programs or other lifestyle intervention programs will be. We need broader policy changes, such as what we are getting with the mandate for restaurant chains to display calorie content for all foods.

Ms. Dentzer: To sum up what we have heard thus far, we have heard about the many encouraging opportunities that ACA will apparently bring to improve the quality of care, cost of care, and health of the nation. Dr. Straube mentioned that the ACA will provide the opportunity for the coordination of care between different groups and as well as institute the creation of a national diabetes report card. Ms. Voss noted that she believed that it will be hard not to include diabetes training in the essential benefits package for insurance plans. Dr. Keckley highlighted that the nation is continuing to grapple with the return on investment for prevention and lifestyle intervention programs. Ms. Tomky has stressed the opportunity to expand the role of the diabetes educator with this new legislation; however, she has raised the question as to whether what is paid for right now is enough to motivate behavioral change. There was also discussion about the merits of using both sticks and carrots, and I think the general conclusion was that we need a balance of both.

Now, going forward, what do you think that this audience will need to keep an eye on with respect to the ACA and the joint congressional panel over the next year?

Dr. Straube: You should continue to gather evidence to show what the impact is of what you do, in terms of clinical care outcomes and overall costs.

Dr. Keckley: We need to focus on finding a solution that allows us to both reduce costs and improve care at the same time.

Ms. Voss: I think we are going to need to see wellness and prevention as integral parts of care that allow us to reduce costs in some way. A healthy population is also a more productive one.

Ms. Tomky: I guess I would just say all hands on deck. We need all of you. We need to be flexible as well as leaders. We have to be at the table when these decisions are made. We need to do everything we can to prevent and take of diabetes.

Business and Emerging Models

BUILDING A NEW DIABETES PAYMENT MODEL WITH PRIMARY CARE, DIABETES EDUCATORS, AND HEALTH PLANS

Donna Zazworsky, RN, MS, CCM, FAAN (Vice President of Community Health and Continuum Care, Carondelet Health Network, Tucson, AZ), Roxanne Butler, RN, MS, CDE (Manager – Diabetes Care Centers, Carondelet Health Network, Tucson, AZ), and Lorry Bottrill, CPA (Chief Operating Officer, Mercy Care Plan, Phoenix, AZ)

After Ms. Zazworsky and Ms. Butler described the various components of the Carondelet Diabetes Care Continuum, they along with Ms. Bottrill discussed the innovative reimbursement structures in place that support this new systems approach. Notably, Carondelet developed a Diabetes Scorecard that stratifies patients into four cost categories based on A1c, blood pressure, LDL, neuropathy score, and retinopathy score; this scorecard allows them to quantify the benefit derived by improving patient outcomes and thus compel health plans to reimburse their services. In addition, Mercy Care Plan (which is in part owned by Carondelet Health Network) provides an annual bonus to physicians when their patients have specific improvements in measures such as A1c and LDL, and participates in shared savings, where physicians get 50% of the proceeds after a certain cost-saving threshold is crossed. While Carondelet and Mercy’s specific payment model might not work everywhere, we hope to see more payment models in which costs are reduced while healthcare professionals are rewarded when they improve care – a win-win for all parties involved. One concern, however, is that patients who are doing the worst may qualify for more services than others; although this is understandable from a return on investment perspective, this may result in perverse patient incentives.

• Ms. Zazworsky and Ms. Butler described the various components of the Carondelet Diabetes Care Continuum. The Carondelet Diabetes Care Continuum aims to provide personalized care for patients, including inpatient services, an outpatient ADA-recognized Diabetes Self-Management Training Program, annual eye and foot exams, medical nutrition therapy, vital signs and labs, telemedicine services, and time with nurse educators, dietitians, “diabetes navigators” (“promotores”, community health outreach workers) as needed or appropriate. Wow!

• Subsequently, they discussed components of Carondelet’s innovative reimbursement model. Carondelet has developed a Diabetes Scorecard that stratifies patients based on A1c, blood pressure, LDL, neuropathy score, and retinopathy score; patients with an A grade have an average annual cost of $1,621, patients with a B grade have an average annual cost of $3,405, patients with a C grade have an average annual cost of $9,720, and patients with a D grade have an annual cost of $21,003. Ms. Zazworsky noted that Carondelet worked with the local business school to come up with these numbers using national data; however, they could not disclose the specific A1c, blood pressure, LDL, neuropathy score, and retinopathy score cutoffs used for their scorecard, as it was proprietary information. (We were dying to hear it!) As we understand it, by using this Diabetes Scorecard as a metric to assess cost savings, Carondelet has convinced some health plans to reimburse certain diabetes education services. Ms. Zazworsky commented that they actually saw patients move from C to B grades, which translated to cost savings for the health plan.

• Ms. Botttrill reviewed Mercy Care Plans’ innovative payment model. Mercy’s payment model includes a number of components: 1) standard fee-for-service, where PCPs, diabetes nurse educators, dietitians, and behavioral health staff are paid for their services; 2) per-member-per- month (PMPM) payment to fund additional care coordination outside of face-to-face visits (e.g., by diabetes navigators); 3) an annual bonus based on improvements in A1c and LDL so that PCPs have the incentive to ensure high quality of care; and 4) shared savings – once the threshold of savings is reached based on the Diabetes Scorecard, physicians share 50%. In terms of engaging health plans, Ms. Bottrill suggested diabetes educators: 1) demonstrate how their programs improves quality and/or reduces costs; 2) define how their services fit in a system of care, not as a stand alone; 3) identify health plans with whom they already have a good relationship and are willing to work on innovative models of care; and 4) find a health plan that has a large number of patients receive services from their organization.

• There is certainly more focus today on cost than there ever has been; we are very glad to see these innovative programs although we hope that patients already in good control will not feel they are not qualifying for tools that would be helpful. We also hope this does not give HCPs a perverse incentive not to treat those who are very ill.

BEYOND DSME: A PHYSICIAN-HOSPITAL-CDE PARTNERSHIP FOR ATTAINING DIABETES PAY-FOR-PERFORMANCE INCENTIVES

Denise Bockwoldt, MS, RN, FNP, BC-ADM (Advocate South Suburban Hospital, Chicago, IL) and Kristin Dellerman, RO, LD, CDE (Advocate South Suburban Hospital, Chicago, IL)

Ms. Bockwoldt and Ms. Dellerman presented data on the success of the Advocate South Suburban Hospital, their uniquely designed CDE-based diabetes clinic in the Chicago suburbs that is focused on having close connections between educators and doctors so as to bring about better patient outcomes. Ms. Bockwoldt began the talk with a simple starting argument: a hospital normally doesn’t realize the financial benefit of diabetes education because current payment systems are not designed to reward quality of care, but rather reward the amount of care dispersed. With this in mind, the Chicago-based Advocate Hospital System and its Physician-Hospital Organization (PHO) developed an accountable- care and pay-for-performance (PFP) model that paid diabetes doctors a small base salary and rewarded them quarterly based on patient outcomes. Ms. Bockwoldt’s diabetes clinic in the Advocate South Suburban Hospital was the first in the system to test this pay-for-performance model. Doctors in the Advocate Hospital System refer diabetes patients to CDE clinic at South Suburban, where Ms. Bockwoldt assesses their treatment regimens and works with patients to bring down their A1c levels through lifestyle changes. In her portion of the presentation, Ms. Dellerman emphasized that focusing on the financial value of a specific program is critically important for healthcare systems, and it is the only means by which diabetes education will become recognized as a critical part of treatment schemes for patients.

• Ms. Bockwoldt noted that current payment systems are not structured to reward quality care. A 2001 Institute of Medicine report called “Crossing the Quality Chasm” concluded that there are two problems with current systems of payment to hospitals and doctors that prevent doctors from being compensated based on their performance. First, the common fee-for- service (FFS) model (in which you can go to any doctor, any hospital, etc.) encourages excess volume of tests, imaging, and office visits. The report stated that while physician visits increased about 30% between 2000 and 2009, tests and imaging went up almost 90% over the same period. Despite this overuse of resources, the quality of care remained unchanged in this time period. The second problem involves capitation, in which healthcare providers get a fixed amount of money per patient per year whether or not the patient visits the office. Ms. Bockwoldt stated that most physicians actually like the capitation model because it encourages a low volume of service and also guarantees a steady stream of income.

• Physician-Hospital Organizations (PHOs), panels of independent physicians that negotiate contracts with health insurance plans for a specific hospital or hospital network, are increasingly seeing the value in pay-for-performance (PFP) payment models. Ms. Bockwoldt likened the old PHO strategy to Costco – they emphasized payments based on the volume of patients treated in order to drive down overall costs, just as Costco sells products in bulk to lower prices. Pay-for-performance models are increasingly seen as cost- effective because they are based on quality/outcome measures, performance measures (how the doctor did in ensuring adherence and frequent/necessary patient tests and visits), and efficiency measures (length of stay, electronic medical records, etc.) – all critical factors to evaluate in order to drive down health care costs.

• Nearly 90% of HMO/PFP programs cover diabetes-related care, and about 87% of diabetes hospitalizations are potentially preventable, yet, they do not emphasize the use of CDEs to track diabetes patients in order to avoid costly and preventable hospital visits by diabetes patients. Ms. Dellerman presented valuable contextual data on this matter. A patient with an A1c of 9-10% (a category that covers the majority of diabetes patients) with other co-morbidities will cost around $11,000 every year. If CDEs are able to help get these patients to A1cs of 7-8%, patients will each cost only $3,700 per year, saving just over$7,000 per year per patient. For HMOs and PFP programs, this would translate to a $700,000savings for every 100 diabetes patients.

• The PHO overseeing the Advocate South Suburban Hospital in Chicago proposed a protocol-driven disease management/diabetes education program targeting patients with A1cs above 9% to help improve the poor performance scores. Physiciansreceived a one-time compensation for agreeing to participate in the program and refer their managed care patients with A1cs above 9%. Physicians and the PHO were given quarterly report cards that highlighted overall A1c reduction, hospital length of stay, readmission rate, and ER usage of their diabetes patients. To date, this program has averaged about a 28% A1c reduction in its patients (e.g., a 2.8% reduction from a baseline of 10.0%), but has faced some stumbling blocks in keeping patients with the highest A1cs coming back to the program.

Questions and Answers

Q: What are your feelings on physicians who try to lower A1cs at any cost, including hypoglycemia?

Ms. Bockwoldt: I’m unsure. We don’t have that problem because our patients are undertreated. We just make sure our patients know that hypoglycemia kills brain cells.

Q: Could you explain how you identify these patients and the legal ramifications of having access to their information?

Ms. Bockwoldt: I think because we were part of the healthcare organization, we had reason to be in their charts. You do have to be very careful that you don’t open charts you’re not supposed to. There isn’t a basic consent that they give because it’s all included in agreed-upon disease management; it comes as part of being a healthcare provider. We do get some patients that are surprised when they’re called to come into our clinic, but the privacy laws allow us to go into their charts because it’s all part of a quality initiative. For some reason, that means we never have issues with privacy. I’m unsure of the intricacies, but I can refer you to the right people if you’re really curious.

REIMBURSEMENT ESSENTIALS

Patty Telgener, RN, MBA (VP of Reimbursement, Emerson Consultants)

Emerson Consultants VP of Reimbursement Ms. Telgener provided a whirlwind tour on the essentials of reimbursement, highlighting some of the recent positive Medicare changes to Diabetes Self- Management Training (DSMT), frequently asked questions about DSMT, reimbursement for CGM training, and the impacts of healthcare reform for people with diabetes. She emphasized that DSMT providers must emphasize the value of their services to hospitals, as they go beyond the direct revenue they provide – DSMT can help to increase revenue of other hospital services, reach pay-for-performance goals, increase referrals, and potentially reduce the number of unscheduled visits or ER encounters due to improved diabetes control.

• Ms. Telgener highlighted some of the recent positive Medicare changes to Diabetes Self-Management (DSMT), including: increases in fee schedules, the removal of co-payments from medical nutrition therapy (MNT), the removal of the multidisciplinary team requirement by CMS, the expansion of telehealth services, and healthcare reform. She noted that reimbursement for DSMT individual face-to-face sessions (G0108) almost doubled, and DSMT group session reimbursement (G0109) increased approximately 50%. Meanwhile, DSMT services may now be furnished by an individual RD, RN, or pharmacist when those services are billed by or on behalf of an accredited DSMT entity (RDs, MDs, DOs, physicians assistants, clinical nurse specialists, hospitals/diabetes centers/Federally Qualified Health Centers [FQHCs], and pharmacies). Currently, RNs and pharmacists cannot bill for their DSMT services; legislation is under way to recognize CDEs as providers so they can directly bill for their services.

• Subsequently, she covered a number of frequently asked questions about DSMT. First, she reviewed Medicare’s definition of diabetes, noting that it is defined as fasting blood glucose greater than or equal to 126 mg/dl on two different occasions, two-hour post-glucosechallenge greater than 200 mg/dl on two different occasions, or a random glucose test over 200 mg/dl for a person with symptoms or uncontrolled diabetes. She stated that Medicare’s definition does not yet include A1c level or cover prediabetes, but AADE is working to expand coverage. Ms. Telgener emphasized that services are only covered when patients are referred from practitioners who specifically order DSMT. Also, she stressed that only recognized programs can bill Medicare for DSMT; currently, programs must obtain accreditation from AADE or ADA in order to qualify for reimbursement. Medicare Part B covers 10 hours of initial training for patients who have been diagnosed with diabetes; Medicare will typically pay for one hour of individual training, and nine of group training. Ms. Telgener clarified that patients can receive DSMT and MNT at the same time; healthcare professionals can be reimbursed for 10 hours of DSMT and three hours of MNT, as long as they are not billed on the same day of service. With regards to justifying DSMT services, Ms. Telgener told audience members to make their value clear to their hospitals: increased revenue of other hospital services, pay-for-performance metrics, increased referrals, and better diabetes control may result in fewer unscheduled visits or ER encounters.

• Ms. Telgener briefly touched upon reimbursement for CGM. She stated that the majority of commercial plans (Aetna, Cigna, United, Healthcare, Humana, most Blue Cross/Blue Shield plans) have written coverage for personal CGM training, whereas Medicare does not pay for personal CGM training; hence, providers should not bill Medicare for these services.

• She discussed the positive impacts of recent healthcare reform on diabetes. Following recent healthcare reform measures, people with diabetes will no longer be denied insurance or be forced to pay higher premiums, and there will be an increased focus on prevention and wellness tools, as well as chronic diseases moving forward. Effective 2010, uninsured people with diabetes are now able to access insurance through high-risk pools specifically created to make insurance available until the provisions banning discrimination are fully in place in 2014, and insurers are no longer able to exclude children with diabetes from their parents’ insurance.

REINVENTING A NATIONAL SYSTEM FOR HEALTH: CREATING A LEARNING SYSTEM FOR PATIENTS

Paul Tang, MD (Palo Alto Medical Foundation, Palo Alto, CA)

Palo Alto Medical Foundation Chief Innovation and Technology Officer Dr. Paul Tang delivered an engaging presentation on reinventing the US health system to increase patient learning, empowerment, and outcomes through the use of electronic health records (EHRs), other technologies, and a more patient-centric model of care. After highlighting the current inadequacies of the US health system, he optimistically noted that public policy can be an effective lever to drive the meaningful use of healthcare IT, and that this, coupled with a new model in which patients are part of their own health team (and have access to some of their own health information), could help to alleviate our current healthcare burdens. He emphasized time and again that patients will be key to transforming healthcare, and that the more we are able to personalize healthcare and get patients engaged, the more successful we will eventually be. In closing, Dr. Tang drew an analogy between our current challenge of improving health to the challenge in the 60’s to reach the moon – it can be done, and when it is, it will be beautiful looking back.

• Dr. Tang discussed the state of the US healthcare problem, highlighting high costs and the increasing burden on the system from the Baby Boomer generation. Currently, the country has healthcare costs in the range of $2.6 to $2.8 trillion per year; to putthis in context, Dr. Tang noted that one million seconds was a week ago, one billion seconds was 30 years ago, and 2.6 trillion seconds was 82,000 years ago. He stated that US healthcare costs are two to three times as expensive as healthcare in the rest of the world; he didn’t think we needed a single penny more, but rather, that we as a nation need to spend the money we have more wisely. To further contextualize the high cost of healthcare in the US, Dr. Tang noted that Americans spend more on healthcare than they do on food or shelter. Despite the higher costs of care, the rate of mortality is still higher than many other countries of the world. Dr. Tang subsequently highlighted the increasing demands that will be placed on Medicare – Baby Boomers started to become eligible in 2011; by 2030 the Medicare-eligible population (people older than 65) will double from 37 million to 77 million individuals. Consequently, the Medicare Trust fund is projected to go bankrupt in 2024.

• Subsequently, he emphasized that public policy initiatives that will bring about improvements in healthcare information technology are essential to help address the problem at hand. In the American Recovery and Reinvestment Act (ARRA) of 2009 signed by President Obama on February 17, 2009, the HITECH provision was put into place. In the provision, the president targeted the universal adoption of electronic health records (EHRs) by 2014, with the goal of transforming the health system, improving outcomes, and improving efficiency. In order to reap the incentives from the provision, healthcare providers would have to demonstrate “meaningful use” of healthcare IT, that is, providers would not be compensated for the sole installation of software; rather, they would have to demonstrate how information was used more meaningfully. The provision had front-loaded incentives to encourage early adoption, with no incentives after 2014, and penalties beginning in 2015.

• Dr. Tang further delineated the definition and requirements of meaningful use of EHRs. According to the HITECH provision, an eligible professional or hospital shall be a meaningful user of the EHR if: it uses a certified EHR in a meaningful manner, exchanges health information to improve the quality of healthcare (e.g., promoting care coordination), and submits information on clinical quality measures. Meaningful use encompasses five categories: 1) improving quality, safety, efficiency, as well as reducing disparities of care; 2) engaging patients and their families (providing access to EHR-suggested patient-specific educational resources as appropriate); 3) improving care coordination amongst providers of care and patient-authorized entities; 4) improving population and public health (e.g., submitting data to immunization registries); and 5) ensuring privacy and security protections. Measures to improve quality, safety, and efficiency include: 1) capturing data in a structured format (e.g., maintaining a current problem list, an active medication list, recording vital signs, recording demographics); 2) using computer-prioritized order entry; and 3) managing populations (e.g., generating a list of patients that identifiers those who are doing well or those who need additional attention, reporting quality measures to CMS). With the more recent Affordable Care Act, there was an even greater emphasis on rewarding providers for performance, instead of merely rewarding them for transactions that occurred.

• He stressed that we need to shift to a patient-centered model of care, which would more likely empower patients to take charge of their own health. Musing on the purpose of health systems, Dr. Tang emphasized that they are supposed to serve patients. However, often times the current health system is structured in a provider-centric, rather than a patient-centric manner. For example, many doctors traditionally tell their patients with diabetes to stop smoking, lose 20 pounds, keep a food diary check blood sugars twice per day, exercise for 30 minutes per day five times per week, et cetera, in a prescriptive manner. Instead, Dr. Tang advocated for providers to approach disease management and health promotion from thepatient’s perspective – figuring out what the patient’s needs are, and what goals they want to achieve (he commended diabetes educators for doing a great job of this). He proposed the notion of a personalized health record – one in which patients express what they want the doctor to know about themselves and their goals (e.g., to live to 90, to be healthy enough to give her daughter a kidney). By reorienting care to the patient’s health, providers could be more effective in achieving outcomes, as patients would be more motivated and engaged to take charge of their own health. As an example of how a patient-centered approach coupled with technology could improve patient engagement, Dr. Tang described a study his colleagues conducted four years ago that allowed patients to upload their blood glucose data to the Internet and visualize trends in their control. In this study, patients were able to come to their own realizations, and take charge of their health by and for themselves (we will try to get the specifics on this study).

MEASURING QUALITY OF DIABETES CARE: PROBLEMS AND PROSPECTS IN AN ERA OF PAY FOR PERFORMANCE (P4P)

David Aron, MD, MS (Case Western Reserve University, Cleveland, OH)

After reviewing the current inadequacies of the healthcare system (the high costs, mediocre quality, and payment methods of care), Dr. Aron discussed the problems and prospects of measuring the quality of diabetes care in an era of pay for performance. A self-proclaimed optimist cynic, Dr. Aron noted that all payment models (salary, capitation, fee for service, and pay for performance) have their limitations, and do not actually incentivize physicians to do the right thing. He emphasized that we shouldn’t be motivated by greed (what he thought pay for performance is based on); expressing great concern, he characterized pay for performance as “de-professionalizing” for anyone who is a professional. As an alternative, Dr. Aron proposed an increased emphasis on public reporting, which would encourage physicians to provide better care without attaching financial incentives (although we note this would not be a full solution). In closing, Dr. Aron noted that diabetes educators must now be able to demonstrate their value in terms that payors will respect in the era of pay for performance.

• Dr. Aron provided context for the problems that pay for performance is trying to fix: the high costs, mediocre quality, and payment methods of care. He noted that as a percentage of GDP, the US spends more than the rest of the world on healthcare – a whopping 16%. Drawing analogies between healthcare spending and military aviation spending, he emphasized that neither is sustainable, and they would bankrupt our nation if they continue on their current trajectories. He mentioned the frequent use of MRIs when they weren’t necessarily needed as “magnificently remunerative imaging.” Dr. Aron pointed out that even with the high costs of healthcare in the US, the quality is not any better than in other countries (in many cases, it is arguably worse); he stated that only approximately 40-60% of people receive the care they are recommended to receive. Dr. Aron believed the amount of progress made in the last three years with regards to improving quality has been absolutely dismal. In addition, he highlighted the long lag time between the development of scientific knowledge and its introduction into practice, noting that only 15-40% of medical decisions are based on scientific evidence (Antmann et al., JAMA 1992; Ellis et al., Lancet 1995). He then emphasized that the current methods of payment don’t properly incentivize physicians to provide the best care. Cynically, he stated that salaries encourage people to do as little as possible for as few people as possible, capitation incentivizes physicians to do as little as possible for as many people as possible, and fee-for-service (the predominant payment method) encourages healthcare providers to do as much as possible but only for those who can pay.

• He reviewed The Joint Commission’s goals regarding the implementation of pay for performance: 1) to align pay with high quality safety practice; 2) to structure financial and nonfinancial incentives towards behavior change; 3) to focus on high importance clinical areas; 4) to base pay on credible, valid, and reliable metrics; 5) to build on shared responsibility of organizations and professionals; 6) to target clear horizons for change, with timely feedback and reward; 7) to reward accreditation and continuous improvement focus; 8) to emphasize interconnected systems, information, and standards; 9) to include the periodic, objective assessments of effectiveness; and 10) to invest in the poor so their performance improves.

• Dr. Aron discussed the flaws of using A1c as a measure to assess performance. Using A1c as an example, he noted there could be measurement uncertainty, and population biases. With A1c, a value of 6.5% could be anything between 6.0-7.0% in an assay with an overall error acceptable for clinical use (Sacks et al., Clin Chem); in addition, seasonal variation of A1c has been observed, with average A1c lowest in late summer and highest in late winter (Miller and Pogach). Compared to Caucasians, African Americans and Hispanic populations tend to have higher A1cs; as such, A1c may not be appropriate as it could overestimate glycemic burden for minorities. Looking at 2008 A1c guidelines, Dr. Aron noted that the ADA recommended targeting an A1c of less than 7%, the VHA-DOD recommended targeting less than 7%, 8%, or 9%, depending on complications and life expectancies, and the NCQA Measures for Public Report looked at A1cs above 9% and under 7% as an accountability measure. He noted that the NCQA’s measures in 2008 did not target the patients most likely to benefit (it ignored the heterogeneity of patient risk factors, e.g., bringing a patient from an A1c of 13% down to somewhere above 9% would have more clinical impact than bringing a patient from 7.5% to 6.5%, yet the former would go unrecognized by the NCQA), did not help providers to do the right thing, did not take into account patient preferences, and could result in unintended consequences (polypharmacy, hypoglycemia, added tests). Musing on guidelines more broadly, Dr. Aron noted that it’s a “pretty ugly situation” that those who are creating the guidelines have such close ties with drug companies. A lot of things influence guidelines (including companies), which then influence measures, and thus perceived value to payers. Dr. Aron noted that he fought tooth and nail to not have A1c of less than 7% as a measure of quality at the VA; most doctors were eventually receptive, whereas insurers had bought into the idea that it would necessarily save them money. As of 2010-2011, the NCQA Measures for Public Reporting now include A1c categories of less than 7% with exclusions, less than 8%, and greater than 9%.

• He discussed a number of other types of measures that could be considered in pay for performance. Dr. Aron stated that linked measures could be a more fair type of measure for pay for performance. Linked measures recognize both the desired outcome, and doing what you were supposed to do to try to get the desired outcome (but not achieving the desired outcome) as successes; they target patients who are the most likely to benefit by accounting for patients’ risk factors and benefits, and help providers to do the right thing. For example, a linked measure could define success or quality as achieving an LDL of less than 130 mg/dl, or having an LDL of greater than or equal to 130 mg/dl with appropriate clinical action – initiation of a high-dose statin, statin dose up-titration within a six month period, repeat LDL testing within six months, or having contraindications noted in statin treatment. When using a dichotomous less than 130 mg/dl, greater than or equal to 130 mg/dl measure, only 73% of patients at the Cleveland VA would have met the success criterion, whereas 87% would have met the success criterion usingthe linked measure. Dr. Aron pointed out that in order to use linked measures, systems would have to have an EMR, or “a staff of slaves” (unlimited resources). Other than linked measures, weighted measures could be used (differentially weighting measures in a composite can reflect thecontributions of each measure to outcomes of interest), and clinical inertia could be measured as well. According to Dr. Aron, regardless of the type of measure used, safety, effectiveness, patient- centeredness, timeliness, efficiency, and equity should be the six main considerations when choosing and defining measures to use for pay for performance. Quality measures should target the patients who are most likely to benefit and help providers to do the right thing.

• Dr. Aron noted that when it comes to patients with multiple conditions, existing quality measures are inadequate, as they are focused on single diseases. Quality measures should weight different conditions to include interactions across diseases, include clinical trade offs, and non-biological complexities.

• He noted that the CMS pay-for-performance incentive will provide quality bonus payments to 260 hospitals based on their performance, in five clinical areas – heart attack, heart failure, pneumonia, bypass, and hip and knee replacement. The top 10% of institutions will get a 2% bonus, while the worst institutions will be penalized. (In our view, 2% represents such a small incentive that we doubt we will see real innovation from hospitals.)

• Dr. Aron found it interesting that pay-for-performance initiatives in general seem only to reward physicians, and not the rest of their healthcare teams. In 2006, approximately 30% of doctors were subjected or involved in financial incentives related to performance; this proportion rose to 36% in 2009.

• Based on his review of literature on pay-for-performance models, Dr. Aron expressed a lack of confidence in their effectiveness. In a systematic review of pay-for- performance systems, their effectiveness ranged from absent/negligible, to strong beneficial (Van Herck et al., BMC Health Services Research 2010). Meanwhile, in the Pacificare Program launched in 2003, pay for performance had very little impact on pre- versus post-implementation performance. The best performers at the beginning did the best at the end, while the worst had no real incentive to improve.

• Dr. Aron highlighted a number of ethical issues that could arise with pay for performance: 1) it could have inequitable impact (large practices with healthcare IT will win; those already doing well will win; non-adherent patients will be shunned, minorities and immigrants will be shunned); 2) it could bring about an inefficient use of resources (more resources would be dedicated towards documentation rather than quality); 3) vulnerable populations could be neglected; 4) quality scores could tell more about patients than their doctors (Dr. Aron noted that a recent study showed that Harvard MDs who worked with poorer patients and more minority patients had scored lower [JAMA 2010]). He noted that organizations that are doing really well will keep doing really well and those close to target will have a real incentive to improve, while organizations at the bottom have little hope of gaining a bonus.

• Dr. Aron delineated a number of assumptions he believed were implicit in pay for performance: doctors are mostly motivated by money, doctors seeking money find it easier to improve quality than to see a few extra patients, MDs won’t cheat, current payment systems are too simple, and MDs currently delivery poor quality should be compensated less.

Questions and Answers

Q: You talked a lot about the negatives of pay for performance. Do you know of any that are successful, and how they are doing it if they’re not using pay for performance?

A: In my view, there are two things that are critical. First is public reporting. It’s important not because the general public is going to look at it, but rather because one physician can see how he or she compares with other physicians. There are very few physicians who don’t want to believe they are the best. I think the competitive spirit is very important. The second thing is that real quality improvement is not about individuals. It’s about teams and the structures, the organizations in which those teams work. The reason VA diabetes care is better in every single measure compared to the private sector has a lot to do with the fact that we invested in a really good EMR that was designed to support clinical care, as opposed to the ones that are being put out now to support billing. I have a much more global view of what it takes to improve quality. I do think people want to do a good job – few docs I’ve met would get up in the morning and say, “You know what? Today is a really good day to not do a good job.” I think it should be more about enabling people to do a good job rather than rewarding it.

Q: We don’t have pay for performance where I work, but they want to start having doctor and nurse teams evaluated on their patients. Do you think that is a good or a bad idea?

A: I think it’s a good idea if it’s done for the purpose of improvement.

Q: I can’t help but reflect on the last three or four days. I’ve heard discussions on how early treatment for prediabetes or pre-prediabetes are not cost effective, so we’re not going to concern ourselves with it. There were booths for The Sugar Association, high fructose corn syrup, and ice cream in the exhibit area. And we wonder why we’re not getting better results? I want to congratulate you for your sanity in an otherwise crazy world.

A: Very rarely is it that I am accused of being sane.

Q: To what extent do you think dealing with multiple conditions is a barrier to improving performance? When you have limited time and a lack of resources, how is it fair to punish healthcare professionals? We still need to provide help to people who are on the front lines. Do you see that on the horizon?

A: I wish I did. I totally agree this is about the system. Every system is perfectly designed to get the results it gets. We provide lousy care, or lousier care than we could because of the way we’ve designed the system – the payment methods, and where the money goes. Personally, I think primary care docs should be at the top of the salary scale and not the bottom. You want to be a specialist because it’s intellectually interesting? Fine, make less money. My view is not a popular view, I might add. I think we’ve got our priorities completely screwed up. What kind of collapse do we have to wait for? How bad do things have to get before something changes? I would have thought things were bad enough a few years ago, but fundamentally very little has changed. Although I am quite cynical, I am an optimistic cynic.

Q: I just want to be able to make a change. I’ve seen a 32-year-old woman on dialysis because of the lack of management, and it breaks my heart. Policy is something that can change the current state. PCPs only have seven to 10 minutes to see patients. Also, minorities are being left behind, and they have the most complications.

A: Where is the leadership of AADE? The leadership of medicine has totally failed in my opinion. Linda?

Linda: Not that I speak for the leaders of AADE any more, but I think the AADE7 focus on behaviors that can be done for prediabetes, diabetes, and even people at risk for prediabetes is important. AADE is really working very closely with minority communities of interest, and there have been presentations at this conference on the matter. What works for behavior change may be different in different cultures. There is a lot published in The Diabetes Educator. I think the leadership of AADE is working with minority groups and the elderly; AADE is very aware of this issue. And now, there is an ADA workgroup for older adults, and I believe they have a consensus conference early next year to develop guidelines for management.

A: Keep in mind that there are initiatives at different levels – things we can do as individuals, things that need to be done at more systems levels. There are plenty of opportunities for individuals to do good, no matter how crappy the system is. A great example is how Brazil dealt with HIV infection – it was absolutely incredible. The infection rate was on the order of the rate in South Africa, and they managed to bring it down to roughly the same rate as the US because they took very different and creative approaches at the individual, organizational, and societal levels. That’s why I’m still an optimist.

Q: I’m a nurse practitioner who was hired specifically to help physicians who are doing poorly on pay for performance. I do think there are positives for the model. We have a high minority population. One thing that pay-for-performance test results highlighted was that poorly performing physicians were performing poorly for a reason. A lot of times they were doing the work, but not documenting it. When we pulled patient lists, we found it very helpful in identifying why some patients weren’t coming in – they didn’t have money to go to the doctor, they couldn’t get a ride to the hospital, et cetera. If done well, pay for performance can work. I do see the risk of physicians getting rid of patients, but our center is very strict about physicians dropping patients – they have to go through a lot of hoops to drop patients.

A: There is something to be said for a system that is designed well. If you design your incentives so that they actually reward the right thing, it’s hard to argue with that. I think it’s important to distinguish between collecting data and evaluating your own performance with pay for performance. As far as knowing how well you do and how you are improving, to me, that is a given. The issue for me is whether financial incentives are going to have much of an effect, especially the way they’ve been done up to now. I do not deny there are some places where there have been good results from pay for performance. On the average though, the data aren’t great. You’ve got a positive result, while someone else has a negative result. If you have one foot in an ice bucket, and the other in boiling water, on the average, you’re comfortable.

Q: I’m a registered nurse who works in home care. I just wanted to make a comment on the African-American communities of interest presentations at this meeting. They were well attended by African-American providers, but they weren’t well attended by the other groups, which didn’t make a lot of sense to me because I’m sure everyone has to deal with African-American patients. I couldn’t understand why you wouldn’t want to learn to take care of those patients, even if it’s only 5% of your patients. I thought that was kind of surprising. The second thing is that in working in home care as a diabetes specialist, I find that a lot of times clinical inertia would have me stomping and getting out of my chair to get somewhere where no one else could hear me scream, because my patient’s A1c might be at 15%, the doctor has the patient on 10 units of Lantus, and the patient is 250 to 300 pounds. I think that working in home care opened my eyes. Getting inside the homes of these people was really an eye opener. It’s not just the minorities, there is poverty everywhere. A lot of times physicians write a prescription but don’t realize their patients can’t afford the money for it, or for food even. Some patients are sharing the meds. I just think that we’re not doing a whole lot, and this is supposed to be the great and wonderful America.

A: For a lot of those reasons, that’s why I’m happy I work at the VA – we don’t have a lot of these issues. You might even call it socialized medicine.

Q: I am a social worker in my diabetes center, and the only one at that. What I have found in my clinical practice, and even in some of the workshops during the conference is that not enough attention is being paid to depression and diabetes. Sometimes I feel like a voice in the wilderness.

A: One of the performance measures for the VA (which has had pay for performance since 1995 at the top executive level, but didn’t reach physicians until about three years ago) was screening for depression. It’s nice when you have a system that can do it and take a systems approach. American medicine is too much of a cottage industry.

-- by Adam Brown, Karthik Chandran, Sam Green, Lisa Rotenstein, Lisa Vance, and John and Kelly Close