In today’s healthcare system, diabetes, and treatment associated with the disease, continues to be a major contributor to rising healthcare costs. Diabetes remains the 7th leading cause of death in the United States, affecting 30.3 million Americans in 2015, or 9.4% of the U.S. population. In 2012 the total cost of diagnosed diabetes, and prediabetes, in the U.S. was $322 billion. Experts agree that in order to lower the growth in healthcare expenditures, specifically for diabetes care, more focus has to be given to prevention and quality management, as opposed to only reactive treatment of this chronic disease. As the healthcare environment shifts from traditional fee-for-service (FFS) to value-based care, Accountable Care Organizations (ACOs) are positioned to play an influential role in successfully addressing the complexities of diabetes prevention, treatment, and management.
The traditional healthcare system is built upon the fee-for-service, or quantity-over-quality, reimbursement framework, where physicians are paid solely on services provided, and where limited coordination exists between specialties. Often patients are left to navigate through the healthcare system alone, which can be confusing, frustrating, and overwhelming, especially for patients who are dealing with the physical and emotional challenges of a chronic disease. Diabetes researchers and healthcare analysts at the Dallas, TX based Baylor Health Care System recognize that in the traditional healthcare model “diabetes care is often fragmented, with patients receiving some care from primary care physicians and other care from specialists such as endocrinologists, nutritionists, and diabetes educators—often with little coordination among care providers.” They go on to say that “providers tend to have little financial incentive to ensure that patients receive quality, comprehensive care” (Collinsworth, et. al). In addition, many providers lack the technology and the access to the same patient data that would help to facilitate better quality care. In the traditional healthcare model patients are left to manage their own care paths, moving across the care continuum in a way that is often complicated and unpredictable.
In the value-based care environment, clinicians intentionally consider the quality of care provided, and the overall outcomes of that care, in relation to cost-efficiency. Physicians and specialists consider “best practices” when treating patients, since they are reimbursed for the quality and efficiency of care they provide. In other words, value-based care emphasizes more proactive, patient-centered, coordinated, and efficient care, predicated on quality performance. The U.S. Department of Health and Human Services (DHH) is committed to the future of value-based care saying that “there is no turning back to an unsustainable system that pays for procedures rather than value.” Through its Centers for Medicare and Medicaid Services (CMS) the DHH created the Medicare Shared Savings Program (MSSP) as a value-based care payment model that utilizes Accountable Care Organizations to encourage a “holistic,” team approach to care, requiring coordination and communication between physicians across specialties. This cross-specialty coordination is extremely important when considering the variety of care needed to address the different stages of diabetes care.
Diabetes patients can require an enormous amount of care, leading to expensive healthcare costs, 2.3x greater than patients without diabetes; however, with their strategic, coordinated-care emphasis and reach, and their focus on quality performance, ACOs are distinctively suited to address the complexities of diabetes care.
Accountable Care Organizations are at the forefront of the value-based care movement. ACOs are voluntary networks of physicians, specialists, surgeons, clinics, care coordinators and educators, dieticians, nursing homes, pharmacies, and hospitals who agree to coordinate care for a patient population, with the goal of improving quality care, while eliminating unnecessary spending. In short, ACOs focus on wellness and prevention, population health management, and value across the continuum of care.
Studies project that 1 in 3 people will develop type 2 diabetes by 2050, placing them at high risk for developing serious health complications, including cardiovascular disease, stroke, blindness, kidney disease and kidney failure, heart disease, and non-traumatic lower-limb amputations. Diabetes patients can require an enormous amount of care, leading to expensive healthcare costs, 2.3x greater than patients without diabetes; however, with their strategic, coordinated-care emphasis and reach, and their focus on quality performance, ACOs are distinctively suited to address the complexities of diabetes care.
For example, under the Quality Payment Program (QPP), ACOs are graded on 31 quality measures (29 individual measures and one composite that includes two individual component measures) spanning four quality domains:
Diabetes related performance measures exist in all four quality domains, collectively covering approximately 75% of the required quality performance measures. This focus underscores how diabetes and its related complications are a significant concentration of healthcare resources in the U.S. and how there is an increased intentionality by CMS to focus on quality care and efficiency in diabetes prevention, treatment, and management.
Diabetes related performance measures exist in all four quality domains, collectively covering approximately 75% of the required quality performance measures.
The Comprehensive ESRD Care (CEC) model is the first value-based care ACO model developed for a disease specific focus. As CMS explains, “The model aims to identify ways to improve the coordination and quality of care for Medicare beneficiaries living with ESRD, while reducing Medicare expenditures.” For example, a diabetes patient with kidney failure (end-stage renal disease), may need life-sustaining dialysis treatments several times a week, and the CEC provides Medicare beneficiaries with patient-centered, high-quality care both in and outside of the dialysis clinic.
When managing the different components of diabetes care, the patient-centered, team-based strategies of ACOs may incorporate diabetes educators or care coordinators who create care plans for patients, who track patient appointments, and who encourage patient engagement. These care coordinators may also make routine calls to survey blood sugar levels or remind patients to take their cholesterol and blood pressure medications. ACOs may also provide Diabetes Self-Management Education (DSME) facilitating the knowledge, skill, and behaviors necessary for patients to care for themselves and to live with their disease. They may also use the Electronic Health Records (EHR) system to send advisory alerts to track patients’ HbA1c, lipoprotein sugar levels, blood pressure levels, smoking status, use of anti-platelet therapy, prescriptions, or hospital admissions.
Certified Diabetes Educator Mary Ann Hodorowicz explains that “it is totally conceivable that [an] ACO patient will access all 7 basic service categories across the care continuum in the stages of his/her life: wellness/prevention, ambulatory care, acute hospital care, extended care, home care, outreach/community services, and transitional care.” For diabetes patients outside the ACO environment, these stages can be confusing, overwhelming, and costly, but for ACO patients, the coordinated care efforts of Accountable Care Organizations can help to prevent or delay diabetes related complications and costs, offering patients quality, efficient healthcare and healthier lives.
North Texas Clinically Integrated Network, Inc. (dba TXCIN) is a non-profit ACO that began in late 2014. A small group of independent physicians aligned to initiate clinical integration and value-based contracting. Partnering with RevelationMD and its state-of-the art information platform, TXCIN has become the largest independent network of physicians in North Texas.
Azar, II, Alex M. “Remarks on Value-Based Transformation to the Federation of American Hospitals. HHS.gov. March 5, 2018. https://www.hhs.gov/about/leadership/secretary/speeches/2018-speeches/remarks-on-value-based-transformation-to-the-federation-of-american-hospitals.html
Collinsworth, Ashley, et. al. “Diabetes and Accountable Care: A Patient-Centered Focus.” Endocrine Today. April 2011. https://www.healio.com/endocrinology/news/print/endocrine-today/%7B52ce0b1f-d94d-4a51-a34b-d3394a6de29a%7D/diabetes-and-accountable-care-a-patient-centered-focus.
Hodorowicz, Mary Ann. “Diabetes Educators in Accountable Care Organizations: Meeting Quality Measures Through Diabetes Self-Management Education and Care Coordination.” AJMC.com. December 2016. http://www.ajmc.com/journals/evidence-based-diabetes-management/2016/december-2016/diabetes-educators-in-accountable-care-organizations-meeting-quality-measures-through-diabetes-self-management-education-and-care-coordination?p=2