Alliance to Reduce Disparities in Diabetes

Enhance diabetes self-management supports

Policy Consideration:
How could coverage for diabetes self-management education and supports be expanded by insurers?

The Problem

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.

Patients 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 there is:

  • Inadequate investment in diabetes management supports;
  • Lack of sufficient funding for providers and/or non-clinical health workers;
  • Lack of health literacy among patients and culturally relevant self-management supports and
  • services available for provider dissemination; and
  • Insufficient integration between the clinical and public health systems and with community-based prevention and education programs.

State 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

Many 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.
  • Researchers 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.
  • The 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 Experience:

  • How can a consistent and core set of self-management support services be included in the Medicaid essential benefits packages of all states?
  • How 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 self-management supports?
  • How can diabetes self-management programs be developed to be culturally appropriate and closely tailored to the needs of vulnerable patients?
  • How could diabetes screenings and self-management training be included in preventive care coverage requirements for private insurers through the ACA?
  • How 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?