Expert Blog

How the Affordable Care Act is Changing the Landscape of Diabetes

Doron Schneider, MD, FACP
General Internist
It is certainly a new world.  As a result of healthcare reform the landscape of diabetes care has forever been altered.  The practicing clinician, patient and healthcare administrators all need to have a firm grasp of these new realities if they wish to prosper now and into the future.  In this blog post I intend to provide a high level overview of the different ways that diabetes care is affected in this brave new world.
·       Insurance coverage – patients will now be provided expanded insurance coverage options with an ability to shop in healthcare exchanges that allow for the comparison of plan attributes.  This informed decision making and choice will allow for optimal choices that should help reduce costs and increase covered services.  It is estimated that approximately 52 million Americans will gain coverage as a result of healthcare reform.   Many of these patients will have diabetes, thus straining the existing infrastructure to provide care to this and other chronic diseases.
·       Preexisting Conditions – insurance carriers will be forbidden to deny coverage outright or  charge higher rates due to the presence of  diabetes (or other medical conditions).
·       Expanded Drug Coverage - in a graduated manner the ‘donut whole’ will be eventually closed to allow for uninterrupted coverage of diabetes medications and reduce the need to switch agents due to coverage limitations. 
Providers and Healthcare Systems
As a result of healthcare reform providers and health systems will be measured on quality, safety and value.   Providers that perform well along these measures will stand to gain additional bonus payments while others will stand to lose both dollars and reputation given the increasing transparency of performance.
·       PQRS – The Physician Quality Reporting System has now been in place for the past 2 years.  As part of the ACA physicians can earn incentive payments of an additional 0.5% above usual Medicare Part B rates. However beginning in 2015 physicians who do not report will be subject to penalties for not doing so.   The associated measures for diabetes include LDL <100, A1C <7, HTN control of <140/80, yearly eye and foot exams.

·       Value Based Physician Modifier – Beginning January 1, 2013 physicians will be measured on the quality and cost of care they provide.  With this novel approach physicians who provide  high quality (defined as low 30 day readmissions, high level of seeing follow up patients’ post discharge in 30 days and low volumes of admissions for acute conditions such as urosepsis, pneumonia and dehydration or chronic conditions such as DM,  COPD and CHF and who have low cost in managing patients with DM, CAD, CHF and COPD will be rewarded with bonus payments. (See Physician Value-Based Payment Modifier under the Medicare Physician Fee Schedule 2013 Final Rule.)

·       Meaningful Use – quality metrics and patient portals  – The role out of Meaningful Use of the EMR stages continues with the stakes going up as well as the level of difficulty.   The quality reporting remains essentially unchanged as we evolve from stage 1 in to Stage 2 criteria.  The same PQRS elements  (including those for diabetes) are used as non ‘core’ measures from which providers can elect to choose from.    Diabetic patients will also benefit from the drive towards increased use and availability of patient portals where the patient will be able to view approved parts of the chart such as their labs.  This will help with empowerment and engagement of the diabetic patient.
·       Physician Compare – The era of consumer driven healthcare is increasing as consumers accelerate their use of comparative websites to find physicians and services that are at the highest quality and the lowest cost.   In line with this directional movement is the Medicare website Physician Compare.  Similar to Hospital Compare where individuals can see an increasing array of measures focusing on healthsystem performance of everything from appropriate use of aspirin in the patient with heart attacks to the appropriate use of imaging for low back pain, Physician Compare is poised to begin publically reporting the PQRS measures and beyond – including patients perceptions of care. Certain of the above PQRS quality measures (including those for diabetes) will be made available to the public via Physician Compare.
·       Non payment for diabetes related inpatient complications – In an effort to reduce harm to patients in the hospital setting provisions of the ACA allow for non-payment for additional care associated with a series of healthcare associated conditions.  These include events as disparate as falls with injury, pressure ulcers, infections as well as the patient who develops ‘manifestations of poor glycemic control’ – including  DKA, HONK and hypoglycemic coma.  Hospitals who have not had diabetes on their radar as a quality improvement opportunity are now forced to consider doing so in an effort to improve care to the diabetic cohort of patients.
·       ACO / Shared Savings Models – One of the largest structural changes to occur as a result of the ACA is the development of the Accountable Care Organization.  Organizations who wish to be deemed an ACO must meet certain criteria that include high levels of quality, information sharing and care coordination.  Providers who care for populations are held accountable to the total cost of care and can benefit from any shared savings due to cost reductions from previous measurement periods.  The incentives thus are aligned to nurture care approaches that result in the greatest value - the best outcomes at the lowest cost.
·       Bundled payments – As the name implies, bundle payments refer to the lumping of payments for all services within a particular episode of care.   There are several variations of this – including payment for acute hospitalizations only and acute hospitalizations as well as care in the subsequent 30, 60 or 90 days.  While some of the methodologies vary, the essence is that incentives align to coordinate care between all parties during the period of bundled payment.  Forty-eight conditions will initially be offered  to have bundled payments and diabetes  is one of them 


Patient Centered Care and Decision Making

Perhaps one of the least well known and discussed aspects of the health reform law is the aspect that authorizes a program to develop and increase Shared Decision Making in medical care.  This intent is to allow for patients to be fully knowledgeable about their healthcare and treatment options and for decisions to be made in alignment with patient beliefs, values and circumstances.    This aspect of the law affords tremendous opportunity for the creation of tools and approaches to fulfill this requirement.   A recent thoughtful review and commentary on this can be found in  the article Shared Decision Making to Improve Care and Cost.

As described above the Accountable Care Act has forever changed the landscape of healthcare in the United States.    With its wide scope and multiple facets few stakeholders will be left untouched.  Directly impacted will be diabetic patients and those providers and health systems that care for them.  Only time will tell just how effective these changes will be in improving outcomes for this vast population of patients.

We invite your comments and thoughts on these new realities.