Lousy Reimbursement is a Barrier to Comprehensive Diabetes Care   (November 21, 2009)

A recent survey of physicians, Physicians' Perceptions of Reimbursement as a Barrier to Comprehensive Diabetes Care, highlights a well-known, ancient, and unsolvable problem: sometimes physicians simply don’t get paid enough to take care of people with diabetes (PWD). It’s certainly easier to scribble a prescription for an antibiotic for an infection than it is to teach a worried patient how to check their blood sugar, give insulin shots, adjust insulin doses, what a carb-counting meal plan is all about, and all the other minutia that are part and parcel of excellent diabetes care. Especially if the physician is in a setting where they are expected to see a patient every 15 minutes. So allied-health specialists (diabetes nurse educators and diabetes dietitians) are inevitably part of every comprehensive diabetes program, to assist in providing that care.

Unlike the situation which exists when hospitalized patients get surgery or ICU care, and the physician can bill for their own services while another source (hospital budget) absorbs the costs of the nursing and ancillary care, physicians caring for outpatients have to absorb all the costs of the ancillary personnel - or do without. And fully-trained diabetes nurse educators, dietitians, and other allied health specialists (especially those with CDE certification, which is the gold-standard of excellence) can be extremely costly for a private practice to hire, and hence many physicians simply can’t afford to set up an office-based comprehensive care diabetes program. Especially as reimbursement for these allied health practitioners is hit-and-miss, and rarely covers the true costs of the payroll and other expenses a physician would have to cover if he/she employed the extra staffers.

Of course, the physician seeing an outpatient with diabetes can refer them to nurse educators or dietitians who are employed by someone else. But doing so runs the unspoken risk that these allied health experts may have only partial (or inadequate) training and may have developed viewpoints that conflict with the physician’s understanding of what constitutes quality care for the patient. A hypothetical example: The physician and patient agree on the need for an insulin pump, but the nurse educator disagrees and tells the patient so face-to-face, undermining the physician’s credibility and the physician-patient relationship. Even the mere threat that there might be such a misunderstanding can discourage physicians from referring – although it’s wrong, the physician’s conclusion might be that it’s better to have the patient learn nothing than learn wrong behaviors.

To be sure, frequently the CDE knows more about diabetes than the referring physician, and some physicians are humble enough to say so to their patients: “I want you to see XXX, who is an expert in diabetes and can help you learn what you need to know, and who will report back to me on what training you’re getting. I have full confidence in XXX’s capabilities.”

But sadly, comprehensive care may simply be a matter of finances. As the publication mentions, “The majority of physician study participants perceived that most of the 10 identified services are inadequately reimbursed—83% to 95% of physicians said Medicaid reimbursement was inadequate, 75% to 89% for Medicare reimbursement, and 67% to 86% for private insurance reimbursement—leading them to spend less time with each patient. This reduction in time was a limiting factor to providing comprehensive diabetes care.”

Is there a solution to this quandary of not enough reimbursement to encourage spending the time needed? Not that I’m aware of. There are, of course, some well-financed diabetes programs, usually in big cities and/or associated with medical schools or University hospitals. But for the average physician, there simply isn’t enough incentive to provide comprehensive care for people with diabetes.

And I don’t think the situation will improve with forthcoming plans to revise the health care delivery system in the United States. Call it rationing or what you will, patients and physicians will simply have to accept the fact that the “best” diabetes care will not always be available – it’s too expensive and too poorly reimbursed.