The Impact of Healthcare Reform on Diabetes Care

Peter Salgo, MD: We’re also living in an era of not just glacial change in reimbursement policy, right? We have healthcare reform. We’ve got the Affordable Care Act on the table, not on the table, it’s in law and it’s constitutional. We have got candidates out there who try to move us to a single payer. We’ve got all kinds of different schemes for Corporate America to try to insure their employees correctly.

How might all these changes impact the care on patients with diabetes? What do you see the future hold?

Steven Peskin, MD, MBA, FACP: It is a seismic change. It is a very exciting time. We have different payment models. So as mentioned earlier, we’re looking increasingly to attempt to pay for value versus volume. We want to see that patients have a better experience of care. We want to see that quality is preserved so that we don’t have amputations, so that we don’t have people that end up blind, and so that we don’t have people that end up on dialysis, which are three horrific complications that all of us are aware of with diabetes.

So how do we do that? Again, we want to pay clinicians appropriately, fairly, and again achieve better outcomes for the populations that they’re taking care of. Those can be done through accountable care organizations or patient centered medical homes where these super subspecialists would be part of what we call the medical neighborhood.

We’ve been a leader in what’s called bundled payment. We’re not doing that in eye care yet, but I’m sure we will. In major joint replacement and in certain cancer diagnoses, we say the orthopaedic surgeon is the orchestra conductor in major joint replacement. The medical oncologist, or perhaps a medical oncologist with a radiation oncologist or the surgical oncologist, are the orchestra conductors in breast cancer. And we know that breast cancer is 28 diseases or more, not one disease. So, paying in a total package, or bundle. Some people would say, “Well, that’s a defined capitation for a particular episode of care.”

Peter Salgo, MD: What I didn’t hear you talk about was incentives for screening and incentives for preventive care. And I thought I heard this when the Affordable Care Act was enacted. I haven’t heard much about it since, and yet, if I hear these guys correctly, that’s where the action is.

Steven Peskin, MD, MBA, FACP: The incentive for screening, and you might call this secondary screening because primary screening would just be looking at eye care in the general population. But, diabetics in particular, are susceptible, vulnerable to a variety of eye conditions.

So, again, we do incentivize or expect our clinical partners to get that dilated exam for diabetics once a year. We do look for them to manage, again, the secondary issues, the peripheral vascular disease, peripheral neuropathy, kidney disease.

Those things are actually encouraged and are paid for either in some pay-for-performance kind of model where there’s increased payments for achieving higher levels of quality, or pay-for-value where we’re looking at quality and total cost.

Peter Salgo, MD: Let’s look at some practical considerations, though. I keep coming back to that awful 50%. You’re out there and you’re trying to, I’ll use the word ‘incentivize,’ though I don’t think it’s an actual word. You’re out there trying to promote screening, trying to promote eye health. And yet there’s 50%.

Is there something wrong with the techniques you’re using? Is there something wrong with the healthcare community in that they’re not doing it? Or is there something more fundamentally wrong in the system that we can’t reach what we want to reach?

Rishi P. Singh, MD: Let me just state that the numbers that we’re at right now have improved greatly over the past years.

Peter Salgo, MD: I don’t even want to know what those numbers are.

Rishi P. Singh, MD: If you look at the managed care organizations, actually it’s better than 50%. Medicare is at 50%, but at [Medical Mutual of Ohio] and a bunch of other places, you’re looking at numbers that are approaching the 60% and 70% range.

So we’re doing better. I think a lot of it’s related to diabetes education. I think we talked about the interventions there. We have to come up with better, efficient screening methods. We don’t have that right now. We are stuck in doing what we do normally, and part of it is also the distribution and execution of this within work environments people are in.

One of the most effective ways of screening people is to do it in offices that aren’t necessarily ophthalmology offices, but in primary care offices, or in their work places.

Steven Peskin, MD, MBA, FACP: In Walmart.

Rishi P. Singh, MD: Sure, in Walmart, in a mall. Those sort of things haven’t been done and are probably going to be done in the future.

Steven Peskin, MD, MBA, FACP: Yes. We’re taking the care to where the populations are rather than having people go to the eye retailer.

Peter Salgo, MD: There are 300 million Americans. Is it reasonable to expect 300 million office visits a year? Probably not, no?

John W. Kitchens, MD: I think it’s good to realize it takes time to turn the Titanic around. I mean, you really can’t turn it around overnight. I think what Rishi alluded to is in some of these systems that were early adopters of screening programs, it’s starting to become successful but it’s going to take continued effort.

We’re in the infancy of the Affordable Care Act and I don’t think we can expect immediate returns right now. I think we can just have a good dialogue and try to realize that it’s about patient education, it’s about physician awareness, and it’s about new technology.

Peter Salgo, MD: So, if I hear what you’re saying, the key would be to look at the micro-climate, not all-comers, but look at where the good practices are, what are they doing, and then try to spread that. Is that fair?

Steven Peskin, MD, MBA, FACP: And there’s so many competing priorities, right? We know that one of the factors for diabetes is overweight. We’ve seen those horrific maps where it goes from light colors to dark, dark red or magenta, and more and more of the United States is people with a body mass index greater than 30.

We’ve got to tackle those issues. Those are very real issues. There are so many variables in the equation and there’s something known as adaptive reserve within clinical practices or change fatigue.

Peter Salgo, MD: What’s that?

Steven Peskin, MD, MBA, FACP: We’ve got the overlay of electronic health records, which have been the bane of many clinicians’ existence, and I’ve heard many people talk about having to spend their weekends charting. So, unintended consequences of electronic medical records. We’ve got other conditions where there are significant issues of screening, secondary prevention. All of these things are coming into play. Is this one issue that is absolutely vital? No question.