Enhance diabetes self-management supports
How could coverage for diabetes self-management education and supports
be expanded by insurers?
The daily, active participation of diabetes patients in
their own care is a critical factor in the
management of their disease progression. In a 2009
article in Patient Education and Counseling, "Patient Empowerment:
Myths and Misconceptions," authors Anderson and Funnell point out that patients
provide 98 percent of their own diabetes care, including healthy eating, being
active, monitoring, taking medication, problem-solving and reducing risks. As
such, a person's daily decisions have the greatest impact on their health, and
they are responsible for the actions and the consequences.xiv
Self-management supports are defined as the range of
educational and supportive interventions provided by health care staff to
increase patients' skills and confidence in managing their health, including
regular assessment of progress, goal setting, and problem-solving support.
need ongoing assistance in that effort. Yet, research underscores the lack of
effective dissemination of diabetes self-management supports by providers to
low-income, at-risk populations and a corresponding lack of implementation of
such supports by this patient population. Adults who rely on Medicaid or are
uninsured, do not receive the amount, type or quality of diabetes
self-management education needed to successfully manage their condition.
According to the experience of the Alliance grantee sites
investment in diabetes management supports;
of sufficient funding for providers and/or non-clinical health workers;
of health literacy among patients and culturally relevant self-management
- services available for provider dissemination; and
integration between the clinical and public health systems and with community-based prevention and education programs.
Medicaid programs are not required by the federal government to pay for
diabetes self-management supports; however, about half of states have elected
to cover such services. In many cases, coverage is limited to just a few
support services and according to the Alliance grantee sites, is usually
inadequate to reimburse for the time required to provide such support. Of note,
Medicare covers diabetes self-management training (DSMT) services for its
enrollees furnished by a certified provider within an accredited DSMT program.
Currently, Medicare covers up to 10 hours of initial self-management training
and up to two hours of follow-up training each year.
The Alliance Experience
of the Alliance's sites have identified the lack of patient diabetes education
and access to diabetes self-management supports as one of the top challenges in
caring for people with diabetes. The barriers created by low health literacy
may result in additional time and more intensive interventions, which may
result in higher costs. Actions by the Alliance's sites have demonstrated the
positive impact of addressing this lack of support. For example:
- The Chicago site has conducted focus groups with
its patients to learn what types of community-based programs would support
diabetes self-management and has created a diabetes-specific directory that
includes information on diabetes education and supports available. Based on
this feedback, the Chicago site plans to create a new program designed to
engage patients in their own communities and empower them to be more active
within the health care setting. Chicago's
preliminary data show that patient education classes and improved
self-management supports have positively affected clinical outcomes.
- The Dallas site has seen improved clinical outcomes, such
as lowered A1C and glucose levels, following the implementation of targeted
diabetes self-management supports, such as providing advanced patient education
and empowering patients to better manage their own care.
at the Chicago site surveyed participants following a culturally-tailored
intervention designed to improve self-management among African Americans with
diabetes and found significant improvements across a range of diabetes
self-management indicators, including self-efficacy and dietary behavior.
Camden Coalition provides diabetes self-management education and training in
both English and Spanish and has recently revised the program to meet the needs
of patients with complex problems.
Policy Questions Arising from the Alliance
can a consistent and core set of self-management support services be included
in the Medicaid essential benefits packages of all states?
could the Medicare practice of coverage for diabetes self-management supports
for enrollees be a model for Medicaid?
- What opportunities exist to leverage current
private market reforms called for under the ACA to increase coverage for
- How can diabetes self-management programs be
developed to be culturally appropriate and closely tailored to the needs of
- How could diabetes screenings and self-management
training be included in preventive care coverage requirements for private
insurers through the ACA?
can new state grants allocated through the ACA for primary prevention of
chronic diseases ($100 million over a 5-year period) be leveraged to help
Medicaid beneficiaries better manage their diabetes?