Providing Guideline-Driven Care to Patients With Diabetes
The survey showed that practice or employment arrangements were as follows: group practice in 32.2% (2–4 physicians 15%; 5 or more physicians 17.2%); solo practice office, 13.9%; and hospital setting, 41.4% (university teaching hospital, 30.3%; community teaching hospital, 7.1%; and community nonteaching hospital, 4.0%). The remaining 12.5% reported working as staff at an HMO or other private plan, being employed by a diabetes manufacturer, working at an accredited or recognized diabetes education program, or working as staff at a community nonteaching hospital.
The results of the baseline model of the standards-of-care economic model show that provider costs exceed reimbursements for all scenarios Table 3, whereas best case provider time estimates reimbursement exceeds costs in five of the six scenarios. Sensitivity analyses showed that the model is highly sensitive to assumptions about provider reimbursement, particularly assumptions regarding the level of office visit code reimbursed. Payers often limit the amount of diabetes education and nutrition therapy allowed, and two of the type 1 diabetic patient vignettes are sensitive to assumptions about the amount of diabetes education and nutrition therapy reimbursed. Provider costs exceed reimbursement for CSII and CGM services for both adult and pediatric patients when baseline case time estimates are used Table 4. CGM but not CSII model results were sensitive to assumptions about provider reimbursement.
The annual gap between provider cost and reimbursement for a typical adult and pediatric diabetes practice was calculated based on the number of diabetic patients seen per year. This estimate is based both on the median number of diabetic patients seen per week for adult and pediatric practices and the mean number of patients seen per year based on the provider survey and data obtained from the Medical Group Management Association. Depending on the number and case mix of patients seen by diabetes care providers, the costs of treating diabetic patients in an adult practice would exceed reimbursement by >750,000 USD/year. For a pediatric practice, costs would exceed reimbursement by >471,000 USD/year. These gaps are increased for patients using intensive management technologies such as CSII and CGM. An adult diabetologist's practice would require a 19% increase in overall reimbursement in order to break even in the baseline case scenario; the individual diabetologist would require a 63% increase. The reason for the higher increase in individual reimbursement compared with the overall practice is the significant disparity between the cost versus reimbursement for evaluation and management services of providing cognitive services to patients with diabetes. This disparity is much smaller for such services such as ophthalmologic evaluation, podiatric care, diabetes education, and nutritional services, which are all considered part of the practice costs.
Results
The survey showed that practice or employment arrangements were as follows: group practice in 32.2% (2–4 physicians 15%; 5 or more physicians 17.2%); solo practice office, 13.9%; and hospital setting, 41.4% (university teaching hospital, 30.3%; community teaching hospital, 7.1%; and community nonteaching hospital, 4.0%). The remaining 12.5% reported working as staff at an HMO or other private plan, being employed by a diabetes manufacturer, working at an accredited or recognized diabetes education program, or working as staff at a community nonteaching hospital.
The results of the baseline model of the standards-of-care economic model show that provider costs exceed reimbursements for all scenarios Table 3, whereas best case provider time estimates reimbursement exceeds costs in five of the six scenarios. Sensitivity analyses showed that the model is highly sensitive to assumptions about provider reimbursement, particularly assumptions regarding the level of office visit code reimbursed. Payers often limit the amount of diabetes education and nutrition therapy allowed, and two of the type 1 diabetic patient vignettes are sensitive to assumptions about the amount of diabetes education and nutrition therapy reimbursed. Provider costs exceed reimbursement for CSII and CGM services for both adult and pediatric patients when baseline case time estimates are used Table 4. CGM but not CSII model results were sensitive to assumptions about provider reimbursement.
The annual gap between provider cost and reimbursement for a typical adult and pediatric diabetes practice was calculated based on the number of diabetic patients seen per year. This estimate is based both on the median number of diabetic patients seen per week for adult and pediatric practices and the mean number of patients seen per year based on the provider survey and data obtained from the Medical Group Management Association. Depending on the number and case mix of patients seen by diabetes care providers, the costs of treating diabetic patients in an adult practice would exceed reimbursement by >750,000 USD/year. For a pediatric practice, costs would exceed reimbursement by >471,000 USD/year. These gaps are increased for patients using intensive management technologies such as CSII and CGM. An adult diabetologist's practice would require a 19% increase in overall reimbursement in order to break even in the baseline case scenario; the individual diabetologist would require a 63% increase. The reason for the higher increase in individual reimbursement compared with the overall practice is the significant disparity between the cost versus reimbursement for evaluation and management services of providing cognitive services to patients with diabetes. This disparity is much smaller for such services such as ophthalmologic evaluation, podiatric care, diabetes education, and nutritional services, which are all considered part of the practice costs.
Source...