AADE Discussion on Value-Based Payment Tackles Tough Questions

Value-based reimbursement can change the direction of diabetes care in ways that will help those on the front lines of care, said Leslie Jebson, an administrator in the Southern Illinois University School of Medicine.

At the annual meeting of the American Association of Diabetes Educators (AADE), Jebson led a lively discussion on the nation’s current transition from a fee-for-service system to one that rewards good disease management and preventive care. The nurses, dietitians and certified diabetes educators (CDEs) may benefit from this change in the long run, but on Saturday they had some tough questions about what they face today.

Many on hand had already felt the effects of payment reform, since diabetes measures are at the top of CMS’ list of metrics that can affect reimbursement. Right now, several attendees said, value-based care has not matured to the point where everyone who affects outcomes bears equal risk.

When, one nurse practitioner asked, will the cost of drugs be part of the equation? Why should diabetes educators be on the hook—or “dinged” as many put it—if they refer to an endocrinologist who prescribes a drug the patient cannot afford?

And when, another asked, will patients be held accountable for their own behavior? She pointed to Jebson’s slide with all the stakeholders in the system and said, “Where is the patient?”

For some, she said, an “entitlement mentality” persists, with patients who expect to see the doctor they want, get the drugs they want, but who refuse to make lifestyle changes that would improve their health. Will these patients ever pay higher premiums?

“I’m getting dinged if they are not listening,” she said.

Jebson replied, “These are the ethical discussions I have with my students all time.” The change to a different way of paying for healthcare will not be easy, he said, but the status quo cannot remain.

How Payment Affects Care, and How Things Are Changing

Patients have been conditioned, in part, by a healthcare system that Jebson said has paid providers for every test, office visit, and emergency room admission instead of making people well. “We have predominantly misaligned incentives,” he said.

With diabetes being the 7^th leading cause of death—and a contributor to the number one killer, heart disease—there’s no question that better diabetes management would save millions. The problem, Jebson said, is that under fee-for-service, “Nonmanaged diabetes is very good for business.”

Endocrinologists made be the lowest-paid specialists, he said, but when one looks at the cost of paying for complications—eye disease, kidney failure—the prices climb. He listed a few: amputating a limb costs from $30,000 to $60,000, with 3 years of follow-up. Wound care runs $300 to $1800 per session. Laser treatments for diabetic macular edema are $500 to $750. Retinal surgery costs 10 times that.

But the “accountable care movement,” as Jebson called it, is taking hold. “We are just on the front end of it—looking more at the cost and the quality, and asking ‘why are we doing these procedures?’”

Value-based care will make providers question whether to order diagnostic tests or scans, “instead of ordering them because we have an incentive to do so.”

The group on hand had some familiarity with payment reform. When asked what value-based care meant, they responded:

“Pay for performance.”

“Preventive care.”

“Patient-focused.”

Jebson responded, “I’m a fee-for-service guy. This is very disturbing.”

The attendees—overwhelmingly women—didn’t reject the idea of value-based care, but they reported the challenges of change they see every day. As high deductible plans proliferate, and patients on the exchanges look only at premiums and not value—diabetes educators are often caught in the middle. One woman said she’s been asked to confront her own patients about their “bad debt” with her hospital. What is needed, she said, is better education about healthcare literacy, and more guidance for patients to choose a plan that meets their needs.

Jebson didn’t necessarily agree. Patients who buy plans with rich benefits tend to use them, he said. As for changing behavior, it’s coming slowly, he said. Some companies offer their employees a choice—if you smoke, you can pay higher monthly premiums, or take classes to quit.

While not all payers are on board, Jepson said, Medicare is rapidly moving toward value-based models. He referenced the many bundled payment initiatives that CMS has pursued, including one for hip and knee replacements that is producing huge savings after only a few months.

“As Medicare goes, often so do the other insurers,” Jebson said. Medicare’s decision to pay for the Diabetes Prevention Program offers a huge opportunity, one attendee observed, and many believe that once it arrives in 2018, commercial payers won’t be far behind.

A data-based solution for insulin management

Jebson offered advice for how to get ready for the change: Use data. Learn to access an electronic health record. Ask for reports, and if they are confusing, ask for help. Use genomic testing to find out which patients are likely to progress to diabetes. Ask the managed care team what changes are coming in diabetes care, and get a seat at the table.

He encouraged the group to use the CDC’s publicly available county-level data, to find out how prevalent diabetes is in their community. He pointed to a map on the slide, and singled out the dark red states in the Deep South that led the nation in diabetes incidence. “That’s the Paula Deen belt, right there,” he said.

“You’ve got to get the data, and you’ve got to know what you’re doing,” Jebson said. The changes that have happened are only the beginning, he warned. “We’re just on the frontier.”

AADE’s annual meeting continues through Monday in San Diego, California.