Business model and profitability
The business model should be adaptable to support changing staffing needs in an SDC network with multiple centers. It is important to provide timely, quality care to patients, but equally important is engaging patients in ongoing care, maintaining a proper rate of patient flow at each clinic every day. Often the model employs a staffing process to match appropriate team members to the number of patients seen at a center, meaning that staff may rotate to different centers depending on need.
For diabetes education services to be covered for reimbursement, the Centers for Medicare and Medicaid Services requires accreditation for all diabetes self-management education and training (DSME/T) programs by the ADA, the AADE, or Indian Health Services. Programs must meet quality standards of the accrediting organization.9
Some federally qualified or academic-based diabetes centers are supported entirely by grant and other public resources, and require grant renewals to become sustainable; other centers have a grant-funded component, and a private- funding component. Unlike diabetes clinics that have a nonprofit component, the SDC that we are associated with (Diabetes America) is completely privately funded and receives no grants to cover clinic or care expenses. We are unable to comment with certainty on whether Diabetes America is unique in its funding. Because of our business model, it is fiscally sound to maintain a mix of patients supported by both private and government payers. Self-payers are accepted, but make up only a small percentage of our patient population.
Costs to patients will vary based on the individual patient’s insurance plan. Many employers, and in turn many patients, are unaware of the placement of diabetes care and education within their comprehensive insurance plan. Some plans cover only the physician visit; all other services are applied towards the patient’s deductible. In some cases, patients may incur substantial costs until the deductible has been reached. In recent years, we have seen deductibles increase for all segments of our population, which can be a financial strain for patients. Patients now scrutinize further which medications or diagnostic testing services they will take or reject based on what their insurance will cover. Patients also face the challenge of having to learn how to calculate their co-payment responsibility in advance.
From our knowledge, many employers are evaluating their diabetes care plans and are beginning to recognize education and preventive services as vital parts of diabetes management that should be covered as part of comprehensive care. As a result, we are working with more employers to design and implement full-service plans that include education and supplies (such as blood glucose testing devices and strips) intended to minimize costs over the long term.
Comparisons of multidisciplinary diabetes team care to standard care
A growing body of research supports the benefits of using an MDT for diabetes care. Specifically, available evidence suggests that a physician-led team encompassing nursing staff, diabetes educators, and dietitians to provide intensive diabetes care may significantly improve patient adherence and glycemic control, as well as the quality of care provided.
A randomized, controlled trial evaluated an MDT approach for the management of diabetes and other chronic conditions at a family health network serving more than 1000 patients in Ottawa, Canada.10 Patients were randomized to receive MDT care or usual physician care. The study measured quality of chronic disease management care based on predetermined performance measures (guideline recommendations) for diabetes, coronary artery disease, chronic heart failure, and chronic obstructive pulmonary disease (primary outcome measure). The study also evaluated quality of preventive care (adherence to the Canadian Task Force on Preventive Health Care recommendations for 6 preventive indicator maneuvers, such as influenza vaccination, eye examination, and hearing examination). The performance measures for diabetes management recommended an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) when appropriate; measuring A1C twice yearly; and giving foot and eye examinations within the past 2 years. After an average of 1.25 years of follow-up, there was significant improvement in the primary outcome measure, with the network’s chronic disease management quality of care improving by 9.2% with MDT care compared with traditional care (P<.001). In addition, the secondary outcome measure of quality of preventive care had also improved, by 16.5%, with MDT care compared with traditional care (P<.001).10 There were no significant improvements in other secondary outcome measures (eg, glycemic control, hypertension, quality of life, and functional status), but, according to the authors, the clinical team did not concentrate on the 2 specific clinical outcomes (glycemic control and hypertension); instead, they had a more general focus of improving the management of the chronic diseases of individuals in their care. Furthermore, the study may not have had enough power to detect a significant difference in these outcomes. With regard to the lack of improvement in quality of life and functional status measures, inclusion of complex older patients who may be at increased risk of irreversible functional decline might have been a limitation of the study.10