DIABETES TECHNOLOGY & THERAPEUTICS Volume 16, Number 12, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/dia.2014.0258

EDITORIAL

The Affordable Care Act, Technology, and Type 1 Diabetes Mellitus Robert A. Gabbay, MD, PhD, FACP,1,2 and Erin L. McGinley1

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he Patient Protection and Affordable Care Act (ACA) of 2010 is the most significant regulatory overhaul to the crumbling U.S. healthcare system since the implementation of Medicare and Medicaid in 1965. The passage of the ACA has stirred a national focus on access to care, healthcare delivery, containing costs, and improving quality after almost 50 years of stagnant healthcare expectations.1 Many people, including those with chronic conditions such as diabetes, have wondered how the new law will affect their care. Diabetes Technology and Therapeutics recently published an excellent article that summarized key features of the legislation in regard to diabetes care.2 This article will highlight the impact of the law for over 1 million patients (and growing) up to 3 million patients in the United States with type 1 diabetes melllitus (T1DM) and how their healthcare delivery will change.3 The ACA has provided guidelines highlighting potential opportunities to reach the ‘‘triple aim’’ by containing costs while increasing quality and patient satisfaction.4 In 2008, the United States spent $7,538 per person on healthcare. This is more than double the median ($2,995) of industrialized countries in the world, equivalent to 16% of the U.S. Gross Domestic Product.5 Medical expenditures for T1DM are estimated at nearly $10,000 a year, compared with $3,580 a year for those without T1DM. For T1DM patients requiring at least one hospitalization, the average yearly cost jumps to $25,858.6 Because of high costs, diabetes—more broadly, type 2 diabetes mellitus—has often served as the target disease for new healthcare delivery models while requiring a high level of coordinated care for both type 1 and type 2 diabetes mellitus among multiple specialties. For persons with T1DM, the ACA helps to address accessibility to insurance coverage along with other benefits. There are no longer denials due to preexisting conditions (historically a big issue) or no annual or lifetime benefit caps, and the potential Medicaid expansion in some states (for lowincome individuals) and the availability of health insurance exchanges will help increase coverage for the 47.3 million uninsured and 31.7 insured but underinsured, including many of those who have diabetes.7 The ACA also includes prolonged coverage for young adults up to the age of 26 years to 1 2

remain on their parent’s insurance coverage (previously the limit was the age of 19 years). Preventive services (e.g., immunizations, diet counseling, tobacco use screening, depression screening, etc.) were also mandated to qualify as free services, also positively impacting those with T1DM to keep up on their routine care. There are also unintended consequences from the ACA that affect patients with T1DM. Health exchange plans often have increasingly higher copayments for office visits along with high deductible plans. The proliferation of tiering of providers or care networks by insurers may also limit access to a specific provider of choice. There has also been a shift of covering employees through the employer to coverage of employees through the state exchanges. Patients are often not fully aware of the complexities of coverage and may not appropriately weigh the multiple options that they need to incorporate into their total care package, such as ambulatory outpatient needs, office visit copayments, prescription drug coverage, and medical device expenses. For example, Walgreens recently shifted 120,000 employees to the health insurance exchanges. A majority of these employees who chose to purchase health insurance through the exchange chose a less expensive plan (42%), with 26% opting to pay more and 32% staying at the same level, giving them more freedom to pick the appropriate plan for their current and future needs.8 Another challenge includes the addition of performance metrics as they tend to contradict the trend that the American Diabetes Association and other professional organizations have moved toward, for example, having more personalization of goals for glycosylated hemoglobin (A1C). Innovative Payment and Care Models

The ACA created an Innovation Center (CMMI) within the Centers for Medicare and Medicaid Services to ‘‘test innovative payment and service delivery models to reduce program expenditures.while preserving or enhancing the quality of care.’’9 From 2010 to 2019, CMMI was allotted $95 billion to test different models of care that may potentially reduce costs and improve outcomes. CMMI also aims to disseminate best practices while engaging stakeholders to

Joslin Diabetes Center, Boston, Massachusetts. Harvard Medical School, Boston, Massachusetts.

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help adopt these new models of care, many of which are focused on diabetes. The Joslin Diabetes Center (Boston, MA) recently received funding from CMMI to expand their ‘‘On the Road’’ program, a community-based diabetes testing and risk assessment program in three states. The program is focused on using ‘‘knowing your numbers’’ (A1C, blood pressure, and low-density lipoprotein cholesterol) while providing lifestyle changes, as well as medication adherence led by trained community health advocates.10 Research suggests that changing the way providers are paid influences clinical practice. In the current fee-for-service system, providers are incentivized to order more services. Transitioning to the world of quality of care, providers are now being incentivized to demonstrate quality outcomes. This change will likely spur significant changes for the delivery of diabetes care. Innovative payment models that are currently being piloted include bundled payments within accountable care organizations (ACOs) and patient-centered medical homes (PCMHs). PCMHs are a model of care for primary care providers that is patient-centered, comprehensive, team-based, coordinated, and accessible and focuses on quality and safety. The PCMH model has recently been fitted for use in specialty care, such as a center of excellence. ACOs build on the strong foundation of primary care PCMHs and are a group of providers or hospitals that come together to provide a network of services to better serve patients by providing them with high-quality, coordinated care within a geographical location. Fundamentally, the transition from a fee-for-service payment system to an outcome- and valuebased system holds significant promise to improve care for those with diabetes. One new payment model is bundled payments,11 which encompasses a single payment package for an overall episode of care. This payment model has been tested primarily for surgical procedures (knee surgery)12 but is now being explored around chronic conditions, such as diabetes.13 The creation of a bundled payment enables diabetes providers to modify their care package to include more services virtually, a type of care delivery not currently reimbursed (e.g., answering patient phone calls or e-mails and responding to meter downloads). Bundled payments allow technology to take the forefront of care, creating a massive opportunity. These technology solutions can include secure, virtual visits with the possibility of replacing a fraction of in-person visits. These virtual visits may not only be more convenient for patients, but may also be preferred with the fast adoption in a technology-enabled generation. Another example includes uploading glucose values with provider-guided decision support, allowing an opportunity to optimize glucose control. An ideal pilot for T1DM would occur in the pediatric T1DM patient population, as they provide a group that is often managed by specialists in a well-defined cohort. Complex T2DM patients would also fit into this same tier of payments as they have historically proven time and again to require more services and coordination of care. These specific patient populations are likely found at a center of excellence, such as the Joslin Clinic or a specialty site that has the infrastructure to treat these patient populations with large numbers. ACOs have been created across the country to represent groups of providers responsible for the quality and cost of assigned specific patient population.14 ACOs encourage a group of providers to manage the health of an entire popu-

GABBAY AND MCGINLEY

lation, focusing on getting their patients to evidence-based goals, by sharing both the medical and financial responsibilities of this population. Ultimately, the goal of an ACO is to reduce costs by providing better coordinated care. In the case of T1DM, costs jump 250% with one hospital encounter per year,6 most of which are largely preventable through better attainment of the ABCs (A1C, blood pressure, lowdensity lipoprotein cholesterol) and screening for early complications. Savings achieved by an ACO are retained by the group and can be distributed and reinvested for better care models. ACOs are an example of the burgeoning use of global payments, a fixed dollar amount over a time period that is meant to contain costs and decrease the use of unnecessary services. Economic incentives now foster investments in care management, which provides between-visit patient engagement and greater diabetes self-management support. Furthermore, increased use of technology to track patients between visits, identifying early hypo- and hyperglycemia atrisk individuals, can provide a return on investment through costs savings. Diabetes specialists have often justified their value to larger healthcare systems based on their downstream revenue. Now, diabetes care providers are critical to reducing costs from preventable complications by leading the health system to savings by preventing costly diabetes complications. The key will be whether ACOs make the appropriate investments in better diabetes care and reinvest savings to support many previously under-reimbursed activities. Ultimately, the health system must decide how to distribute the shared savings. The complexities of dividing the shared savings prove difficult and may not be invested within diabetes care. It may be difficult to determine whether or not better diabetes outcomes are due to care provided by the primary care physician or the diabetologist. In Massachusetts, the birthplace of many features of the ACA, a majority of savings often go to primary care and not to the rest of the diabetes team such as endocrinologists, certified diabetes educators, dietitians, exercise physiologists, and mental health providers. Many T1DM patients identify their diabetologist as their main provider; often, primary care providers are not comfortable with the management of T1DM patients. Therefore, one could imagine specialty PCMHs15 that provide a majority of care for certain patient populations, such as T1DM. This PCMH for T1DM patients could include diabetologists, educators, and other members of the diabetes care team and, while engaging in the principles of PCMHs, include population management, team-based care, wholeperson orientation, and care management. Those specialty centers that function as centers of excellence, such as the Joslin Clinic and its affiliates, would be ideal locations for specialty PCMHs ultimately, becoming responsible for the total costs of care for those with T1DM.16 As a population-based approach and value-driven global payments replace the fee-for-service reimbursement model, an increased need for diabetes technology will emerge. Whether this technology is decision support tools to entangle the plethora of data elements for pumps, glucose meters, exercise trackers, and food records, or integration of ‘‘big data’’ to identify high-risk individuals with T1DM for outreach—these technologies will help stratify risk in populations with cloud-based aggregation of data and decision support tools for patients and providers. Global payments

AFFORDABLE CARE ACT IMPLICATIONS

provide the rationale for moving forward with these technologies to support care management and to make it one of the most effective quality improvement approaches to reduce A1C.17 Although the ACA payment changes can stimulate adoption of diabetes technology based on improved outcomes, medical device companies now face an excise tax on their products starting at 2.3% in 2014.18 Within a 6-year time period, this tax is expected to raise $20 billion to support the insurance coverage expansion but may inevitably hurt many small, innovative start-ups. The shift toward outcome-based payments focused on total costs of care can provide the impetus to change the care of diabetes. Diabetes, one of the costliest chronic diseases, has the opportunity to change from historically being a cost center in most hospital systems to a source of cost savings. The ACA indeed has the potential to transform health care in the United States for those with T1DM. Through wider coverage and access, new payment models that focus on outcomes that spur technology development, and a greater emphasis on population health, the healthcare sector will require new tools to aggregate, analyze, and provide actionable decisions support for patients and providers to improve outcomes. The focus on outcomes will only increase the demand for and value of diabetes specialists to improve the health of patients with T1DM, thus creating a spur and need for new technology solutions. References

1. Patient Protection and Affordable Care Act. 42 U.S.C. x 18001 et seq. (2010). 2. Burge M, Schade D: Diabetes and the Affordable Care Act. Diabetes Technol Ther 2014;16:399–413. 3. Chiang J, Kirkman M, Laffel L, et al.: Type 1 diabetes through the life span: a position statement of the American Diabetes Association. Diabetes Care 2014;37:2034–2054. 4. Berwick D, Nolan T, Whittington J: The triple aim: care, health, and cost. Health Aff (Millwood) 2008;27: 759–769. 5. Squires DA: The U.S. Health System in Perspective: A Comparison of Twelve Industrialized Nations. Issues in International Health Policy, Vol. 16. Publication number 1532. New York: The Commonwealth Fund, 2011. 6. Tao B, Pietropaolo M, Atkinson M, et al.: Estimating the cost of type 1 diabetes in the U.S.: a propensity score matching method. PLoS One 2010;5:e11501. 7. Schoen C, Hayes SL, Collins SR, et al.: America’s Underinsured: A State-by-State Look at Health Insurance

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12. 13. 14.

15. 16. 17.

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Affordability Prior to the New Coverage Expansions. New York: The Commonwealth Fund, 2014. Pinsker B: Walgreen Shifting Employees to Private Health Care Exchanges. Daily Finance. September 18, 2013. www .dailyfinance.com/2013/09/18/walgreen-shifting-employeesto-private-health-care-exchanges/ (accessed July 29, 2014). Centers for Medicare and Medicaid Services: About the CMS Innovation Center. http://innovation.cms.gov/about/ index.html (accessed July 23, 2014). Joslin Diabetes Center Recieves $5 Million Grant for Innovative Diabetes Project. www.joslin.org/news/joslinreceives-federal-CMMI-grant-for-innovative-diabetes-project .html (accessed August 1, 2014). Health Affairs Blog: The Payment Reform Landscape: Bundled Payment. http://healthaffairs.org/blog/2014/07/02/ the-payment-reform-landscape-bundled-payment/ (accessed July 29, 2014). Rastogi A, Mohr B, Williams J, et al.: Prometheus payment model: application to hip and knee replacement surgery. Clin Orthop Relat Res 2009;467:2587–2597. Strujis J, Baan C: Integrating care through bundled payments—lessons from the Netherlands. N Engl J Med 2011; 364:990–991. Centers for Medicare and Medicaid: Accountable Care Organizations (ACO). www.cms.gov/Medicare/MedicareFee-for-Service-Payment/ACO/index.html?redirect = /ACO (accessed August 1, 2014). Spatz C, Bricker P, Gabbay R: The patient-centered medical neighborhood: transformation of specialty care. Am J Med Qual 2013;29:344–349. Joslin Diabetes Center: Affiliated Centers. www.joslin.org/ bp/affiliated_centers.html (accessed August 6, 2014). Shojania KG, Fanji SR, McDonald DM, et al.: Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis. JAMA 2006;296: 427–440. Center on Budget and Policy Priorities: Excise Tax on Medical Devices Should Not Be Repealed: Industry Lobbyists Distort Tax’s Impact. www.cbpp.org/cms/?fa = view&id = 3684 (accessed August 4, 2014).

Address correspondence to: Robert A. Gabbay, MD, PhD, FACP Joslin Diabetes Center Harvard Medical School One Joslin Place Boston, MA 02215 E-mail: [email protected]

The Affordable Care Act, technology, and type 1 diabetes mellitus.

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