Alliance to Reduce Disparities in Diabetes

Executive Summary

Policy Considerations That Make the Link: Connecting Community Experience and National Policy to Reduce Disparities in Diabetes

***Executive Summary***
November 2012

Barriers to Reducing Disparities in Diabetes Revealed Through On-the-Ground Programs
The Alliance to Reduce Disparities in Diabetes is a national program launched and supported by The Merck Company Foundation. Alliance sites, located in five communities across the country, have been working since 2009 to improve health care delivery and outcomes among those Americans most at risk for diabetes – African-American, Hispanic/Latino and Native American adults. Each site, with teams based in Camden, NJ; Southside of Chicago, IL; Dallas, TX; Wind River Indian Reservation,WY; and Memphis, TN, has implemented multi-faceted, evidence-based programs designed to reduce disparities and improve diabetes care and outcomes for those who are most burdened by or at risk for the disease.

While Alliance sites are making substantive progress in addressing diabetes disparities in their communities, they also report facing an array of structural barriers in the health care delivery and financing systems that have limited the success of interventions. These include:

  • The health care system’s focus on payments based on units of care, on specialty care and high-cost, high-tech interventions; 
  • State credentialing standards that present barriers to payments for vital health workers.
  • Technologies, costs and policies that can obstruct timely, comprehensive and robust exchange of patient information;
  • A lack of designated, adequate and consistent payment for community health workers that can provide people with diabetes needed links to community resources and education; and
  • Inadequate integration between health care systems and public health departments that limit care coordination and optimal use of resources in assisting diabetes patients.

Reducing Diabetes Disparities Requires National Policies that Reflect the Local Experience

As the number of those who are most burdened by or at risk for diabetes continues to rise, it is critical that national policies aimed at reversing this trend consider the on-the-ground experiences of those working to improve the health outcomes of those most affected.

According to Alliance sites, the health outcomes of those who are underserved would be improved with greater flexibility for health care professionals to shape their care delivery in ways that maximize the use of evidence-based interventions and reflect the specific needs of their communities. Through the lens of the local experience, health policies could be better shaped to promote deeper reductions in health care disparities.

Alliance Policy Considerations Leverage Learnings from Local Programs to Address Health System, Provider and Patient Needs

To advance a national conversation on ways to overcome the systemic and structural barriers to providing effective diabetes care to those most in need, the Alliance has developed a series of policy considerations drawn from the local experience.

The considerations pose a series of questions surrounding the identified need to realign financial incentives affecting health systems, providers and patients as a mechanism for reducing disparities in diabetes. The considerations were developed based on in-depth interviews with the Alliance sites, a review of the literature, and consultation with a group of experts from a range of academic, government, consumer and provider organizations.



Core Concept Encourage greater integration of public health and health care systems
Policy Consideration In what ways could public health be better integrated with health care systems to increase communication and care coordination for people at risk of or living with diabetes?
Supporting Information Disease management is a critical component of an effective health system and public health has a significant role to play. The lack of coordination and communication between health systems and public health agencies has created a fragmented delivery system, especially for low-income, uninsured or underinsured individuals who must rely on safety-net providers for their care.
Alliance Grantee Experience The Alliance sites are partnering with public health organizations to identify ways that linkages between clinical providers and public health can improve care coordination and help to identify those at risk of diabetes or its complications.


Core Concept Share and report community-wide health data
Policy Consideration What types of incentives or regulatory requirements are needed to prompt health systems to a) share timely patient data and b) consistently collect and report health data by race and ethnicity?
Supporting Information Quality improvement efforts that are designed to reduce health care disparities in diabetes require providers and health systems to more consistently and uniformly measure disparities. There is a need for more uniform, complete and timely collection of patient data and for the development of community-based datasets. Health systems, however, face many challenges in collecting comprehensive data including tight budgets, inadequate staff expertise, and lack of IT infrastructure to meet the regulatory requirements for data collection.
Alliance Grantee Experience Alliance grantees are creating data-sharing systems to provide information across institutions that could serve as a model for broader use.


Core Concept Eliminate incentives that encourage underinvestment in low-income, high-risk patients
Policy Consideration Although current law and regulations have safeguards against financial incentives that encourage under-investment in health care for low-income, at-risk patients, how can those safeguards be further strengthened and what steps can be taken to improve the ability to monitor their effectiveness?
Supporting Information Health systems that treat at-risk, low-income populations face many challenges in helping patients to achieve better health. Emerging quality improvement policies and payment structures may unintentionally create perverse incentives for providers serving minority patients. For example, health systems may selectively choose to treat only those patients for whom providers can demonstrate the greatest improvement with the least amount of effort, thus jeopardizing access to quality health care for at-risk, low-income patients.
Alliance Grantee Experience Alliance sites are creating quality improvement collaboratives to ensure that the diabetes health care needs of the people they serve are met.



Core Concept Optimize Accountable Care Organizations’ (ACOs) abilities to reduce disparities
Policy Consideration Given increasing health care costs and the importance of coordinating care for the most at-risk patients with diabetes, how can ACOs be structured and utilized to reduce disparities in diabetes?
Supporting Information Low-income, minority populations lack consistent access to high-quality care, which can result from multiple factors including lack of cultural competency on the part of the physician, lack of follow-up by patients, and problems with inconsistent health care coverage. ACOs have been suggested as a way to help improve health care coordination and by proxy, quality of care.
Alliance Grantee Experience Alliance grantees have been instrumental in working with state legislators to enact legislation establishing ACO demonstration projects.


Core Concept Support deployment of Community Health Workers (CHWs)
Policy Consideration Given the important role CHWs play in reaching underserved, high-risk populations, how can coverage for these services be expanded?
Supporting Information CHWs have been shown to improve the health outcomes of those affected by disparities in diabetes by providing patients with health information and assisting them with navigating the health care system, especially in poor and underserved communities.
Alliance Grantee Experience Alliance grantees are employing the use of CHWs to help provide higher-quality, more integrated care for the people they serve but have experienced barriers related to reimbursement mechanisms for these workers, including the need for training and credentialing standards.



Core Concept Enhance diabetes self-management supports
Policy Consideration How could coverage for diabetes self-management education and supports be expanded by insurers?
Supporting Information The daily, active participation of diabetes patients in their own care is a critical factor in effective disease management. Yet, according to the experience of the Alliance grantee sites, there are many barriers to assisting patients with self-management including inadequate investment in diabetes self-management supports and lack of sufficient funding for providers and/or non-clinical health workers.
Alliance Grantee Experience Alliance sites are conducting patient focus groups to determine what types of diabetes self-management supports are most effective and result in improved health.