Addressing Issues

Aligning Payment Policies with Quality Improvement: Barriers to Integrated Care

Key barriers include

• Measurement of quality care is often not connected to goals for improvement. For example, to achieve success in increasing the number of patients in a practice who receive A1C testing twice a year, goals for improvement need to relate directly to this outcome - such as physician reminders that an A1 C test is due - rather than less specific actions such as informing providers that testing patients twice a year is recommended.
• The level of funding for redesign of health care delivery systems is low partly because the need for redesign has only recently become clearly apparent.
• Information technology for health care is not well developed and much of the medical record is handwritten. Investment in technology has not been a high priority.
• It is difficult to finance alternative systems for care such as phone and email care, group visits, and team care. Demonstration of the effectiveness of these approaches needs to support reimbursement requests.

Health care organizations may resist investing in quality improvement if they see no economic reward, and in some cases suffer a financial penalty for these activities. There are numerous examples of payment policies that work against the efforts of clinicians, health care administrators, and others to improve quality health care. For example, redesigning care systems to improve follow-up for patients with diabetes through electronic communication may reduce office visits and decrease revenues for a medical group under some payment methods.5

While the causes of under diagnosis and inadequate management of diabetes are multifaceted, the actions (or lack thereof) of those who pay for the care - public and private purchasers - have contributed to quality care levels remaining lower and more variable than they should be. Specifically, purchasers have promoted the problem through four distinct actions:

• Assuming that systems for quality care are in place.
• Making contracting decisions based on price without also examining plan and provider performance.
• Using transaction-based rather than health outcomes based payment structures that discourage quality improvement and promote waste.
• Failing to engage the consumer (employees and beneficiaries) on quality issues.3

Public and private employers represent the largest block of consumers in the health care industry. Yet these employers and their employees continue to accept under use and to pay for overuse, misuse, and waste without a clear strategy for addressing these problems. Until purchasers (and consumers) demand better diabetes care, there is little reason for the system to change,3 despite the best efforts of clinicians to provide high quality, evidenced-based care.

Affordable insurance coverage

Affordable insurance of diabetes-specific services, prescription drugs, equipment and related medical supplies is essential to diabetes management. Poor health insurance coverage appears to contribute to increased microvascular complications (nephropathy and retinopathy) in Mexican Americans with non-insulin-dependent diabetes. Of 255 people surveyed, 26 percent lacked any type of health insurance, and 28 percent relied on county- or federal-funded clinics rather than private doctors as their primary source of care. Microvascular complications were more common among those who received their health care from a clinic versus a private doctor, and among those who lacked health insurance coverage for outpatient doctor visits and medications.7

A study of factors that prevented patients with newly diagnosed diabetes from seeking medical care found that of seven variables examined, only lack of health insurance correctly predicted those patients who failed to seek medical care for their diabetes.8 The economic burden on families can be substantial. Researchers examined the health insurance experience and out-of-pocket health care costs of families with a child with type 1 diabetes. They found that most families with a child with type 1 diabetes had health insurance, but incurred out-of-pocket health care costs that were 56 percent higher than those in the control families without diabetes.9

The cost of prescription drugs may be a barrier to patient participation in comprehensive diabetes management given the need for polypharmacy in adult patients for the management of glucose, lipid, and blood pressure as well as for microvascular and macrovascular complications of diabetes. 10-14

Medicare covers the following prescribed services, tests and supplies for people with diabetes: 15

• diabetes self-management training
• medical nutrition therapy services 16
• glucose monitors, lancets, and test strips
• A1C test
• dilated eye examinations
• therapeutic shoes 17

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Continue to Issues: Aligning Payment Policies: Fixing the Quality Care Problem