February 4, 2014

2014 Third-Party Reimbursement for Diabetes Supplies

I do not understand the American Diabetes Association (ADA). This article on the Diabetes Care section, covers many of the points that should have been covered, but I am in doubt about the enthusiasm and sincerity even being part of the 2014 Guidelines.

The point of self-management education (inpatient and/or outpatient) is delivered by an interdisciplinary team and this will help people with diabetes adjust their daily regimen to improve glycemic management. Diabetes self-management education teaches individuals with diabetes to assess the interplay among medical nutrition therapy, physical activity, emotional/physical stress, and medications.

Today, self-management education is understood to be such a critical part of diabetes care that medical treatment of diabetes without systematic self-management education is regarded as inadequate. The weakness of today is doctors that will not support education, support needed testing supplies, and the lack of certified diabetes educators to assist in education.

The following is quoted, “Numerous studies have demonstrated that self-management education leads to reductions in the costs associated with all types of diabetes. Participants in self-management education programs have been found to have decreased lower-extremity amputation rates, reduced medication costs, and fewer emergency room visits and hospitalizations.”

To achieve optimal glycemic control, thus achieving long-term reduction in health care costs, individuals with diabetes must have access to the integral components of diabetes care, such as health care visits, diabetes supplies, self-management education, and diabetes medications. As such, insurers must reimburse for diabetes-related medical treatment as well as for self-management education programs that have met accepted standards, such as the American Diabetes Association's National Standards for Diabetes Self-Management Education and Support. Furthermore, third-party payers must also reimburse for medications and supplies related to the daily care of diabetes. These same standards should also apply to organizations that purchase health care benefits for their members or employees, as well as managed care organizations that provide services to participants.”

It is recognized that the use of formularies, prior authorization, competitive bidding, and related provisions can manage provider practices and costs to the potential benefit of payors and patients. Social Security Act Title XIX, section 1927, states that excluded medications should not have “a significant clinically meaningful therapeutic advantage in terms of safety, effectiveness or clinical outcomes of such treatment of such population.” A variety of laws, regulations, and executive orders also provide guidance on the use of such controls to oversee the purchase and use of durable medical equipment and single-use medical supplies associated with the management of diabetes.”

The last paragraph has me wondering if they are telling payors (insurance providers) to do what they want when it comes to diabetes. I know many of the current people on Medicare are attempting to opt out of the mail order supply sources and returning to local pharmacies for their diabetes supplies. This has meant an increase in costs the patient is required to shoulder, but some patients are unwilling to accept the second rate and unreliable testing supplies they were required to use under the mail order business.

The following is quoted because Medicare is totally ignoring this and could care less about what the Medicare patient is doing to manage their diabetes. “Though it can seem appropriate for controls to restrict certain items in chronic disease management, particularly with a complex disorder such as diabetes, it should be recognized that adherence is a major barrier to achieving targets. Any controls should take into account the huge mental and physical burden that intensive disease management exerts upon patients with diabetes. Protections should ensure that patients with diabetes can readily comply with therapy in the widely variable circumstances encountered in daily life. These protections should guarantee access to an acceptable range and all classes of antidiabetic medications, equipment, and supplies. Furthermore, fair and reasonable appeals processes should ensure that diabetic patients and their medical care practitioners can obtain medications, equipment, and supplies that are not contained within existent controls.”

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