Expanding Financial Coverage for Education and Treatment of Pre-diabetes

While the burden of the costs of diabetes care cannot be refuted, policy-makers do not agree upon the sources of potential funding and strategies to address the burden.  How much does diabetes cost us?  In 2017, the estimated cost of diagnosed diabetes care was about $327 billion for America (ADA, 2018).   About $237 billion of this is from direct medical costs; the remaining $90 billion is due to reduced productivity.  About 67.3% of diabetes care in the U.S. is paid for my government insurances, such as Medicare, Medicaid, and the military.   Only 2% of this cost is paid by the uninsured, and about 30.7% is paid for by private insurances.   To sustain any kind of changes to reduce cost of care or improve care for individuals with pre-diabetes or diabetes, financial strategies will have to be considered carefully.

Ultimately, to save costs related to diabetes, strategies need to be aimed at prevention. Preventive measures could focus on healthy lifestyle modifications and alterations to environments of communities to facilitate these healthy behaviors. Specifically, we need to promote physical activity, weight loss, and increasing fiber intake (Bergman et al., 2012).  Policies including strategies to educate the public and providers need to be developed to increase detection of at-risk individuals and appropriately refer them to programs that will intervene to promote healthy lifestyle modifications.  Agricultural policies should not be discounted, as the agriculture and food industries have great influences on the health of our nation. 

To promote the necessary changes for the prevention of diabetes, we must advocate for widespread health system changes, encourage funding and facilitation of evidence-based research, bring these issues on the agenda for policy-makers, and provide them with the evidence they need to support their case for the changes (Bergman et al., 2012).  The only way changes will be sustainable is if they are aimed at prevention.  Transitioning to a proactive system, focused on early detection and prevention, rather than continuing to be a reactive system, focused on medications and treatments, will be essential to reduce costs associated with the burden of diabetes in our nation.

American Diabetes Association. (2018). The cost of diabetes. Retrieved from https://www.diabetes.org/resources/statistics/cost-diabetes

Bergman, M., Buysschaert, M., Schwarz, P. E., Albright, A., Narayan, K. V., & Yach, D. (2012). Diabetes prevention: Global health policy and perspectives from the ground. Diabetes management, 2(4), 309–321. doi:10.2217/dmt.12.34

For so long, healthcare providers have not had technological innovations, restricting access to patient information and the ability to monitor patients.  Patients also have increasing access to health information, specifically with the use of patient portals.  With advancing technological opportunities to improve and personalize healthcare, and more informed consumers due to the availability of information, can also come more problems.  Providers are also able to monitor patients from home now, in some cases.  With all technological advancements, privacy and data storage must be considered, to maintain ethical boundaries.

Electronic health records (EHRs) store information, and can take inputted information and check for problems, such as conflicting patient allergies and prescribed medications.  In cases of patients with diabetes or pre-diabetes diagnoses, the EHR can alert providers to potential safety problems prior to their occurrence or suggest assessments or referrals, leading to better patient outcomes (ONC, 2019).   By analyzing patient information and alerting providers when necessary, EHRs can offer improved risk management in clinics. They also allow many different users to access information and results through the Internet.  

Periodic reports can be sent to providers to monitor a patient’s vital signs at home, such as blood pressure, or blood glucose results, without inconveniencing the patient too much. The sensor technologies can alert providers to abnormal results, allowing the provider the opportunity to intervene.  However, with increasing wireless transmission of data comes potential for privacy and security compromise.

As storage of electronic health information increases, the potential for data mining also increases (Meingast, Roosta, & Sastry, 2006).  Data mining allows large amounts of human medical data to be analyzed to recognize patterns.  Prior to data mining, personal information must be de-identified.  However, discrimination is still possible.

Since technological modalities are being rapidly incorporated into care of patients with pre-diabetes and diabetes, many ethical considerations will arise when discussing future uses of technology. Who should have access to the data, and who owns it?  Where should information be stored, and for how long? Should data mining be allowed, and what is the best way to remove personal identifiers from the data? Several questions will need to be answered to ensure the information we store as healthcare providers is safely secured for the protection of our patients and ourselves. While the Health Insurance Portability and Accountability Act (HIPAA) provides a foundation, health care is rapidly changing, and more specific guidelines need to be established that will be consistent across the states.

Meingast, M., Roosta, T., & Sastry, S. (2006). Security and privacy issues with health care information technology. Conference Proceedings: Annual International Conference of the IEEE Engineering in Medicine and Biology Society. doi: 10.1109/IEMBS.2006.260060

The Office of the National Coordinator for Health Information Technology (ONC). (2019). Improved diagnostics & patient outcomes. Retrieved from https://www.healthit.gov/topic/health-it-and-health-information-exchange-basics/improved-diagnostics-patient-outcomes

With the use of technology growing rapidly, it is no surprise that innovative technological solutions for managing diabetes are rapidly emerging, as well.   Since individuals with diabetes must regularly monitor blood glucose levels, they are dependent on technology to do so.  Since the population with diabetes is growing, technology and pharmaceutical companies are dumping money into innovative diabetes management strategies. 

In 2018, Fitbit invested $6 million to work on continuous glucose monitoring technology (Mobius MD, 2018).  Intuity Medical has received over $40 million in funding to launch technologies that will simplify the lives of individuals with diabetes, including a monitoring system that does not need separate test strips and lancets and a cloud-based platform for providers and patients to track factors that affect glycemic control (Muoio, 2018).  In 2017, continuous glucose monitoring became a hot topic, which allows patients to track blood glucose levels without having to stick themselves multiple times a day (Mobius MD, 2018).   Technologies that do not require blood draws are also being researched heavily, along with diabetes medications that do not have to be taken daily, but can be injected less frequently, which have already become available by pharmaceutical companies.   

Programs like Weight Watchers have been using strategies similar to the National Diabetes Prevention Program (NDPP), using group-based interventions and methods to track behavior (Stewart, 2015). The YMCA also enrolls many participants in efforts that focus on prevention.  In individuals with pre-diabetes who are not recommended to test blood glucose on a daily basis, technology to track exercise and diet habits may be particularly useful.  Smartphone applications may be beneficial in the pre-diabetes population. 

University of California in San Francisco researchers have even begun a project to trial a smartphone application that could alert a user that they should get checked for diabetes by detecting vascular changes, using a smartphone’s camera and flash functions (Newman, 2019). Their preliminary research found that the algorithm could “identify individuals with diabetes 72% of the time”, and if they inputted information about other risk factors, that number was increased to 81%.  Additionally, the application “correctly identified people as not having diabetes 97% of the time”.  Since almost one in four Americans has diabetes but does not know, this kind of technology could be a low-cost, non-invasive method for individuals to screen for diabetes at home.

In contrast to the public sector, which aims to protect citizens, the private sector must protect investments, and strives to produce a return on these investments.  They can affect policy through front groups, lobbyists, and research funding and donations. Three major companies control insulin sales, totaling 99% of the insulin market, and prices for insulin have increased, despite being discovered almost 100 years ago (Beran, Hirsch, & Yudkin, 2018). Although these programs may claim to support patient assistance programs through donations, analyses of policies suggest their initiatives are not sustainable or transparent and actually are negatively impacting access to their medications. There are also various national and international diabetes associations that acknowledge that access and prices of diabetes treatment options are a problem, but fail to address the issues, possibly due to funding by pharmaceutical or food companies. However, the American Diabetes Association (ADA) has launched a petition and campaign for affordable insulin, which is the first of its kind. The interdependence among private and public sector institutions and policies continues to cause problems with the allocation of resources for diabetes care in the United States.

References

Beran, D., Hirsch, I. B., & Yudkin, J. S. (2018). Why are we failing to address the issue of access to insulin? A national and global perspective. Diabetes Care 41(6),1125-1131. doi: 10.2337/dc17-2123

Mobius MD. (2018).The astounding pace of mHealth innovation in diabetes management. Retrieved from https://www.mobius.md/blog/2018/06/the-astounding-pace-of-mhealth-innovation-in-diabetes-management/

Muoio, D. (2018). Glucose monitor maker Intuity Medical brings in $40M. Retrieved from https://www.mobihealthnews.com/content/glucose-monitor-maker-intuity-medical-brings-40m

Newman, T. (2019). Could a smartphone app detect diabetes? Medical News Today. Retrieved from https://www.medicalnewstoday.com/articles/324643

Stewart, J. (2015). Local examples: Innovations in preventing diabetes. Retrieved from https://www.thirdway.org/memo/local-examples-innovations-in-preventing-diabetes

“Simply put, in the absence of a radical shift towards prevention and public health, we will not be successful in containing medical costs or improving the health of the American people.” -President Obama (Alper, 2014)

Only 3% of national health expenditures are used for preventative services, even though health depends largely on behavioral and environmental factors, rather than medical care or genetics (Alper, 2014).   Three major components of healthcare reform are recognized globally, as nations are continuously working to increase access, improve quality, and control costs of healthcare (McDonough, 2014). Since President Lyndon Johnson signed the law establishing Medicare and Medicaid services insurances in the sixties, controlling rising costs of these programs has been concerning.  Although his actions primarily aimed to increase access to healthcare, the costs and quality associated with care have been of increasing concern since his presidency.  In 2010, President Barack Obama signed the controversial Affordable Care Act (ACA) into law, hoping to address many of the new issues that have emerged in healthcare.  The launch of marketplace sites to purchase healthcare, came with many problems for customers, and many of the reforms have made complete repeal of the ACA unlikely.

The ACA has components that were intended to remedy problems associated with limited health literacy, but two other major initiatives were also introduced in 2010, which also strived to address problems associated with health literacy (Koh, et al., 2012).  These were the National Action Plan to Improve Health Literacy, by the Department of Health and Human Services (HHS), and the Plain Writing Act of 2010.  Policies, which improve health literacy and promote language that is easy for readers to understand, are essential for the population with diabetes and pre-diabetes.  A cross-sectional study in St Louis, Missouri reported findings indicating most patients with diabetes are unintentionally nonadherent to treatment plans, suggesting educational interventions may be helpful and should be designed for patients with limited health literacy (Fan, Lyons, Goodman, Blanchard, & Kaphingst, 2016).  Patients’ attitudes toward their diabetes were investigated using questionnaires, revealing that many people with diabetes may not understand the HbA1C level, and may need simpler explanations of key diabetic concepts, with less medical jargon (Elliott, Harris, & Laird, 2016). 

Features of the ACA, which focus on patient-centered care, may be the most popular portions of the legislation (Koh, et al., 2012).  Since findings suggest patients are usually unintentionally nonadherent to treatment plans, educational programs can be helpful in the treatment of patients with diabetes (Fan, et al., 2016).   Diabetes self-management education and support (DSMES) is supported by a large body of evidence, in demonstrating that it can improve knowledge of disease, self-care, HbA1C, weight, mortality, coping, and quality of life, while decreasing weight and costs (ADA, 2018). These programs focus on the individual’s values, while responding to and respecting the patient’s preferences and needs.  The goals of the patient-centered treatment plan for a patient with diabetes should focus on decreasing complications and maintaining, or improving, quality of life.  Of course, to improve quality of life, one must first assess what this would mean to the individual. Nonjudgemental, empathetic approaches, using empowering language, are suggested for patients with diabetes, rather than blaming them for “noncompliance” (ADA, 2018).  Public sector policies can affect diabetes care significantly by regulating funding and healthcare requirements and promoting health literacy, but the terminology that is used in the legislation needs to be carefully selected.

References

Alper, J. (2014). Population health implications of the affordable care act:Workshop summary. Washington, DC: The National Academies Press.

American Diabetes Association. (2018). Standard of medical care in diabetes – 2019. Diabetes Care 2019, 42(Suppl. 1). doi: 10.2337/dc190Sint01

Elliott, A. J., Harris, F., & Laird, S. G. (2016). Patients’ beliefs on the impediments to good diabetes control: A mixed methods study of patients in general practice. British Journal of General Practice, 66(653), e913–e919. doi:10.3399/bjgp16x687589

Fan, J. H., Lyons, S. A., Goodman, M. S., Blanchard, M. S., & Kaphingst, K. A. (2016). Relationship between health literacy and unintentional and intentional medication nonadherence in medically underserved patients with type 2 diabetes. The Diabetes Educator, 42(2), 199–208. doi:10.1177/0145721715624969

Koh, H., Berwick, D., Clancy, C., Baur, C., Brach, C., Harris, L., & Zerhusen, E. (2012). New federal policy initiatives to boost health literacy can help the nation move beyond the cycle of costly ‘crisis care’. Health Affairs (Project Hope), 31(2), 434-443. doi: 0.1377/hlthaff.2011.1169

McDonough, J. (2014). Health system reform in the United States. International Journal of Health Policy and Management, 2(1), 5-8.

Key governmental agencies in policies related to diabetes include (Patton, et al., 2015):

• Agency for Healthcare Research and Quality (AHRQ)
• Centers for Disease Control and Prevention (CDC)
• Centers for Medicare and Medicaid Services (CMS)
• Deparment of Health and Human Services (HHS)
• Department of Veterans Affairs (VA)
• Food and Drug Administration (FDA)
• Health Resources and Services Administration (HRSA)
• National Institute for Occupational Safety and Health (NIOSH)
• National Institute of Nursing Research (NINR)
• Occupational Safety and Health Administration (OSHA)

In 2018, Governor Ducey signed House Bill 2258, which required that a diabetes action plan team be established in the department of health services and include team members from the Arizona health care cost containment system (AHCCCS), the public safety personnel retirement system, the Arizona state retirement system, the department of administration benefits services division, and stakeholder organizations, including insurers, a nationally recognized diabetes association, and the Arizona, diabetes coalition (AZDHS, 2019).  This action plan team should create a report every two years, as discussed in the first post.  The stakeholders who contributed to the 2019 action plan included Vitalyst Health Foundation, American Diabetes Association (ADA), Arizona Diabetes Coalition and Leadership Council, and Blue Cross Blue Shield of Arizona (Arizona State Legislature, 2019).

CMS is very influential in administrative health care; this agency regulates payment and approval for Medicare beneficiaries, after organizations and individuals contribute opinions and comments (Patton, et al., 2015).  This is another key time when a nurse or any person can influence rules and regulations, by contributing public comments during this period, in addition to exercising the right to vote. 

Nursing is a respected profession by many, and nurses can influence others with their thoughtful language.  Historically, nurses have been involved in policy-making by engaging in professional associations, committees, and regulatory government agencies (Patton, Zalon, & Ludwick, 2015).  Nurses are specifically helpful at determining terminology to help finalize rules and regulations.  Correct professional terminology in regulations is important at the institutional, state, and federal levels.  Policy-makers seek advice and input from the public, and the opinions of healthcare professionals is welcomed in concepts they may not be familiar with.   

Arizona Department of Health Services. (2019). House bill 2258: Diabetes action plan and report. Retrieved from https://azdhs.gov/documents/prevention/tobacco- chronicdisease/diabetes/house-bill-2258-diabetes-action-plan-report.pdf

Arizona State Legislature. (2019). Diabetes action plan team; report. Arizona Revised Statute, 36-142. Retrieved from https://www.azleg.gov/search/oop/qfullhit.asp?CiWebHitsFile=/ars/36/00142.htm&CiRestriction=diabetes

Patton R.M., Zalon, M.L., & Ludwick, R. (2015). Nurses making policy: From bedside to boardroom. New York: Springer.

When considering respect for autonomy in healthcare policy related to diabetes, the person with diabetes or pre-diabetes should have the ability to make his or her own decisions based on personal values and beliefs (Longest, 2010). Regardless of whether educational treatment options will reduce a person’s incidence of diabetes or reduce costs, respecting patients’ autonomy will require allowing them the choice to receive such education.  Meaning, in no situation should an individual be forced to attend an educational program or receive a treatment for his or her diabetes or pre-diabetes. 

Policy decision-making for diabetes must also apply the philosophical principle of justice; this can be a topic of debate related to the distribution of benefits and burdens on members of society in a fair way (Longest, 2010). We do not want to waste resources on those who are not in need, or take away from individuals who may have genuine needs.  When determining our perspective on justice related to diabetes education, we must consider whom we would like the resources and burdens distributed to, and how these decisions will be made.

We should act with beneficence, to intentionally do good.  Knowingly burdening some individuals for the benefit of others violates this principle (Longest, 2010).  In health policies, a similar principle of nonmaleficence should be reflected in the quality and quantity of services, requiring that we “do no harm”.  There can be significant consequences of the health policy-making process.  All possible outcomes of policy implementation must be considered carefully to avoid negative ethical impacts.

Healthcare policies related to the coverage of diabetes and pre-diabetes education and treatment options have significant ethical impacts on Arizona residents.  Healthcare policies can affect costs of services, preventing some residents from receiving services.  If a patient is told that he or she needs to alter lifestyle choices to prevent diabetes, but the educational program ordered by the provider is not covered financially, the patient may decide to forego the program.  In a few years, this patient could develop type 2 diabetes and the complications that can go along with it.  Now, not only does this patient need frequent labwork, assessments by multiple providers, and daily medication to prevent complications, but still needs the education that was initially ordered by the provider.

In 2014, more money was spent on discharges for diabetes complications than any other emergency department visit or hospital stay in Arizona (Arizona Department of Health Services [AZDHS], 2018).  Since the majority of type 2 diabetes care in the United States is paid for by government insurances, such as Medicare, Medicaid, and the military, wouldn’t we rather find a way to financially cover these preventative educational programs for patients with pre-diabetes and avoid the diagnoses of type 2 diabetes (American Diabetes Association [ADA], 2018)?  Considering the cost of care for DM in the U.S. is $327 billion per year, covering these services could save billions of dollars (ADA, 2018).  Perhaps, we could also find more innovative ways to expose the general population to educational tips to prevent type 2 diabetes.

Regardless of costs, diabetes can affect quality of life, result in amputation of extremities, and even result in death.  We must tackle the difficult questions associated with justice in the care of patients with diabetes and pre-diabetes, in order to act with beneficence. 

References

American Diabetes Association. (2018). The cost of diabetes. Retrieved from http://www.diabetes.org/advocacy/news-events/cost-of-diabetes.html

Arizona Department of Health Services. (2018). Diabetes in Arizona: The 2018 burden report. Retrieved from https://www.azdhs.gov/documents/prevention/tobacco-chronic-disease/diabetes/reports-data/diabetes-burden-report-2018.pdf

Longest, B.B. Jr. (2010). Health policymaking in the United States (5th ed.). Chicago, IL: Health Administration Press.