Payment Reform Reveals Value of Diabetes Educators in Driving Down Healthcare Costs, Joslin's Gabbay Says

The nurses, dietitians, exercise specialists, and other professionals who make up the world of diabetes educators have always offered value to people learning to manage their disease. But until recently, they had to operate within a healthcare system that wasn’t designed to reward their efforts, according to the chief medical officer of Joslin Diabetes Center.

Joslin’s Robert A. Gabbay, MD, PhD, FACP, an expert on healthcare transformation and payment models, offered the opening keynote address at the 2018 meeting of the American Association of Diabetes Educators (AADE), who have gathered in Baltimore, Maryland. Gabbay, who is also the editor-in-chief for Evidence-Based Diabetes Management^™, a publication of The American Journal of Managed Care^®, said the shift from volume-based to value-based care offers AADE members new opportunities, as both practices and health systems need help in the shift toward prevention that has always been the mainstay of diabetes self-management and support.

“We’ve long been in the fee-for-service [FFS] world, where the incentive is to do things,” Gabbay said. “We’re moving to one where value is key.” He explained how the things about healthcare that never made sense suddenly make sense when one understands how hospitals historically made their money.

Teaching people to manage their blood glucose was a cost center, not a revenue generator, while hospitals made lots of money from the complications of diabetes—like surgery to remove a toe or dialysis due to renal failure. Spending on healthcare in the United States kept rising, he said, but people weren’t any healthier. But healthcare transformation—and payment reform—will change everything. As health system are paid set fees to care for populations of patients, they will make investments in those professionals and services that take costs out of the system.

“That shift is happening as we speak,” Gabbay said. “That will fundamentally change the value of the work that you all do,” adding that diabetes educators are typically underpaid for services they offer—a comment that brought applause.

“If you can deliver value and do it well, the health system gets to keep the money. The old cost center will be the savings center,” Gabbay said. “Our surgical colleagues who’ve been at the top of the hill for so long—they will be a cost center.”

Gabbay walked the audience through the Medicare Access and CHIP Reauthorization Act (MACRA), an overhaul of physician compensation that Congress passed in 2015 to hasten the shift to value-based care. MACRA includes a provision for MIPS, the Merit-based Incentive Payment System (MIPS), which is a transitional scoring system that most practices will use as they move from FFS toward advanced alternative payment models. MIPS, Gabbay noted, has 4 components, and the most heavily weighted one is quality.

Read more on how MACRA incentivizes value-based care delivery.

“What does all this have to do with diabetes?” he asked. “Many of the quality measures are diabetes measures—measures that you know,” such as low-density lipoprotein (LDL) cholesterol, blood pressure, and how many patients in the practice or health system have glycated hemoglobin (A1C) below 9%.

“You all are the value people,” Gabbay said. Physicians and health systems are still figuring out how the payment is changing, but as they do, it will be clear that they need diabetes specialists to bring their skills to mission of avoiding unnecessary procedures and hospitalizations. “This is not something in the distant future. It’s happening right now.”

Tools for savings. Population health management requires the use of registries—something that Elliot Joslin pioneered in the 1890s when he carefully tracked lists of diabetes patients and their symptoms. By doing so, Joslin determined that controlling blood glucose was critical to management of the disease.

The shift for educators, Gabbay said, will be to think about measures not just for individual patients, but also for a population—and to think about how to target attention and resources to those patients who are at greatest risk, and whose improved health represents the greatest opportunity for avoided costs. This means not just treating the patients who show up but finding the ones who don’t show up and figuring out when to bring them in for care.

Gabbay sees 3 areas where diabetes educators could help practices and health systems during the transition to value-based reimbursement:

1. Practice coaching. Practices often struggle to make the leap to a patient-centered medical home, which provides care in a team-based environment and connects patients to all the services. This is an area where diabetes educators can make a difference, he said. Becoming a medical home requires “negotiated goal setting, problem solving, empowering, team dynamics, and cheerleading,” he said, all components of diabetes self-management and support. “Any of that sound familiar?” he asked.

2. Care management. If the goal is to reduce costs and improve quality, diabetes educators are well-positioned to be experts in risk stratification and working with high-risk patients, both those that are newly diagnosed with type 2 diabetes (T2D) well above 7% A1C and those who have been diagnosed for some time but cannot achieve their target goal. Data from the Agency for Health Research and Quality show that 10% of the patients account for two-thirds of the costs; the key, Gabbay said, is finding that 10%.

3. Augmenting digital care. There’s lots of excitement about using digital tools to manage diabetes, Gabbay said, but researchers are finding that early engagement tends to wane over time. A key seems to be finding a way to combine the technology with the human touch to ensure ongoing use. “Somewhere along the way there must be a person,” he said, and with stiff competition in the digital therapeutics space, “They are all desperately searching for people like you.”

Gabbay encouraged diabetes educators to speak up and highlight their value to health systems. “In so many ways, there’s never been a better time for diabetes educators,” he said. “Once they realize what you do, they’ll be beating a path to your door.”