Paving the Way to a Healthier America
ADA's recommendations for health reform
For the millions of Americans who voted in November, health care was a key issue. And now, for the officials taking their seats in state government, Congress, and the White House, the work is just beginning. This country's health care system is in crisis, and that's bad news for people with diabetes. Not only is diabetes one of the most costly medical conditions, but people with diabetes often have trouble getting even the basic care and insurance coverage they need. The American Diabetes Association convened a special health reform task force last year to guide change that will benefit people with diabetes, highlighting the major issues that are at stake as we enter 2009.
Paying for Health Care
Diagnosed diabetes in the United States cost an estimated $174 billion in 2007, according to a study published in the March 2008 issue of Diabetes Care. That's an increase of 32 percent since 2002, and it means that one in five health care dollars is spent on someone who has been diagnosed with diabetes.
What can be done? The first step is increasing disease prevention efforts, say task force members, and key to that is encouraging healthy behaviors. In addition, ADA's task force calls for efforts to increase the efficiency, effectiveness, and equality of care—among at-risk minority groups and people from different economic backgrounds—that will promote health and cut costs in the long run.
"We pay the most [of any country] in the world for our health care, yet we're not No. 1 for outcomes," says Ann Albright, PhD, RD, president of health care and education at ADA, director of the Division of Diabetes Translation at the Centers for Disease Control and Prevention, and a member of the ADA task force. "We must address not only how much we will pay, but what we are willing to pay for. If someone needs dialysis for kidney failure, that is an important covered benefit. But we need to look at investing in interventions that will prevent the development of kidney failure."
In addition to expensive procedures and hospitalizations to treat the later stages of chronic disease, emergency room visits by people without access to primary care place a significant strain on the health care system. "In many cases, this more expensive care could be avoided with adequate access to preventative and/or primary care," according to the task force report.
Another major cost comes from medication and supplies. Last year, Americans with diabetes paid $12.5 billion on drugs they needed to treat their diabetes—nearly double what they spent 6 years ago.
Affordable, Adequate Coverage
"People with diabetes face insurance nightmares," says John Anderson, MD, chair of ADA's advocacy committee and member of the task force. "Diabetes is expensive, and they're the first people to be tossed out of the system as uninsurable."
Insurance needs to be accessible to all, affordable, and adequate, the task force recommends. In some states, health insurance policies already must be sold on a "guaranteed issue" basis, meaning nobody can be denied coverage regardless of any "preexisting condition." The task force calls for this to be the standard in all states.
The group also pushes for making insurance portable so that people with diabetes don't have to make job choices based solely on insurance coverage. "You have individuals who can't afford to start their own business, become consultants, or leave their employer because they can't find affordable insurance in the marketplace," says Anderson. "They have to make entire life decisions based on insurance availability."
Caring for Chronic Diseases
Chronic diseases are the top cause of death and disability in the United States, and account for 75 percent of health care spending. Part of the cost burden taken on by insurance providers, health care providers, and individuals has to do with the fact that not enough is being spent up front to save on big ticket items later.
"Our health care system is better designed to deal with acute issues—infectious diseases, among others—that used to be more common than chronic diseases," explains Albright. "Now, however, [there are more] chronic diseases like diabetes, hypertension, heart disease, asthma, that are much more common. ... These chronic diseases, especially diabetes, require ongoing monitoring, education, and support in order to be managed well."
The structure of the current health care system largely hinges on the question "How will providers get paid?" As a result, "Most [professionals] gravitate toward procedural-based specialties where they receive higher reimbursement, like cardiology, surgical specialties, neurosurgery, and orthopedic surgery," explains Anderson. "Seventy-five percent of health care dollars are spent on chronic diseases, yet provider reimbursement doesn't reflect that."
And in primary care, managing chronic illness just doesn't pay. "Physicians are just paid for the office visit," Anderson says. "All of the coordination of care that is needed to properly care for a patient between office visits is not reimbursed."
Some states are beginning to come up with alternatives. "In Oregon and California, some providers are paid a fee for the global management of a number of patients," Anderson says. "[We need to figure out] how does the system help pay somebody to do more than see patients? The Center for Medicare and Medicaid Services and insurance companies have to look at the pieces of the pie, where the money is being spent, and how to incentivize chronic disease management."
Developing and Distributing Incentives
The task force emphasizes that financial incentives will be key to effective health reform. In addition to encouraging physicians to provide better care to those with chronic diseases, other basic changes to the health care system—in doctor's offices as well as in hospitals—may mean better health and long-term cost savings. One example is the implementation of improved electronic systems for managing medical records and registration, and for monitoring health services system-wide.
Other suggestions include offering financial incentives to providers to institute systems that reduce medical error and creating a national center that could coordinate field-wide studies of procedures and treatments.
That said, it is patients who should take the primary role in care with self-management of wellness and chronic disease, the task force recommends. "You have to make taking care of people with chronic disease attractive to health care providers," Anderson says. "The most cost-effective way is to spend your money on the front end and educate patients to get their disease under control."
Personal Responsibility and Prevention
When it comes to type 2 diabetes in particular, health reform begins with increasing prevention efforts. The ADA health reform task force states that health literacy is an important first step, as is giving incentives that promote healthier lifestyles.
"Currently, whether patients see a provider every 3 months for their diabetes, or only once a year to do refills, it makes no difference," Anderson explains. "Whether they stop smoking, or continue smoking, there is no incentive. Patients also have to be incentivized to engage in their disease process."
ADA supports workplace wellness and disease prevention programs, community-level education and prevention, and incentives for schools to provide healthier menus and more physical education. The task force urges health care providers to work with community services to provide ongoing support to patients.
"People spend minutes, maybe hours in the health care system each year. They spend days, weeks, and months outside the system," says Albright. "It's important that we look at how to connect what people learned and what guidance they're given in the system, and see what they can do with that outside of it."