ACA Will Help Spark Boom in RPM

RPM means remote patient monitoring and will be here to stay under the Affordable Care Act (ACA). Initially this started with heart patients, but it will expand. And yes, diabetes is on the list of types of patients that will be remotely followed. Now why would they do this, considering that few type 2 diabetes patients receive education on managing their diabetes? Not only that, but without the personnel available to educate people with diabetes, how can they expect patients with type 2 diabetes to feel anything but contempt for remote patient monitoring.

I expect to see something appear in the American Diabetes Association (ADA) website as early as this summer hinting at the possible monitoring to be done and when it will start. Then, I am guessing that the ADA 2014 guidelines will have much more to say about this. If not this summer, then announcements will happen by the summer of 2014 and will be part of the ADA 2015 guidelines. It is coming and of this, I have no doubt.

This press release says a lot about RPM for five major chronic illnesses that will grow by 6-fold by 2017. This is because the ACA will be pushing hospitals and physicians to stop the revolving door treatments by hospitals. In 2012, clinicians reviewed remote patient monitoring data for about 227,000 patients with congestive heart failure (CHF), chronic obstructive pulmonary disease, diabetes, hypertension, and mental illness. The figures include a number of other patients with asthma, coronary artery disease, and hemophilia.

CHF patients were almost half of PRM in 2012. In 2017, diabetes will overtake CHF and the monitoring will grow by 67.5 percent from 2012 to 2017. The next fastest group of RPM will be patients with mental illness. Demand for this monitoring comes from patients and private insurers, which seek to reduce costly hospitalizations. All of these trends build on an even larger one, an aging population beset with chronic conditions.

The ACA will bring financial incentive into play to promote RPM and this will mean rewards for physicians and hospitals that comply. In addition to sharing payment for an episode of care, they will earn a bonus, or take a pay cut, depending whether they come under or exceed a cost target. With the financial incentives and penalties that the ACA can and will enforce, hospitals and physicians will have money reasons to physically monitor patients. Then there are those providers that want to remotely patient monitor at home for improved care whether there are monetary rewards or not.

The one factor not included in this article if the role of the Food and Drug Administration and how fast they will be approving these remote monitoring devices. This could be the flaw in the current thinking, but this should not delay progress for long as CMS and most insurance payers are on board and looking to the benefits this will provide.

Currently, the task of reviewing RPM data falls to nurses at third party triage and call centers services. They then alert the relevant physician to flagged changes. Currently, under the existing fee-for-service reimbursement, there is no incentive to take remote medical data that will not result in a billable office visit. Under the ACA, there will be many financial incentives for physicians to change their way of doing business including penalties.

Presently, remote-monitoring systems are relegated to call centers, but this will change as pressure is put in place for the electronic health records (EHR) to be capable of tracking this data. Yes, the manufacturers of EHR systems are balking; however, congressional pressure is being applied quite liberally to force them to make their systems more responsive to receiving RPM data and working together (interoperability) to correspond with competing EHR systems. This can only be positive as the Health and Human Services and Centers for Medicare and Medicaid are applying pressure saying their systems will not meet useful standards, as they exist. The pressure is to make all systems “telehealth-ready.”

National Standards for DSME and DSMS – Part 3

The fourth standard states, “A coordinator will be designated to oversee the DSME program. The coordinator will have oversight responsibility for the planning, implementation, and evaluation of education services.”

This works well in larger cities where two or more certified diabetes educators (CDEs) work for the same office, however, I do have to wonder about CDEs working alone in some of the smaller offices, clinics, and hospitals. As the DSME continues to evolve, the coordinator should play a pivotal role in ensuring accountability and continuity in the education program. Will coordinators need to travel from large offices to smaller offices and rural areas as an area coordinator? This is something to be considered. The standard does state, in some cases, particularly in small practices, the coordinator may also provide DSME and/or DSMS.

The fifth standard states, “One or more instructors will provide DSME and, when applicable, DSMS. At least one of the instructors responsible for designing and planning DSME and DSMS will be a registered nurse, registered dietitian, or pharmacist with training and experience pertinent to DSME, or another professional with certification in diabetes care and education, such as a CDE or BC-ADM. Other health workers can contribute to DSME and provide DSMS with appropriate training in diabetes and with supervision and support.”

Maybe historically, nurses and dietitians were the main providers of diabetes education, but in recent years, this has been expanded to mainly pharmacists. It is therefore natural to see this in the hierarchy of people in the literature and whom they assign the functions of the different standards to for completion. At least the obligatory continuing education is included as a way of segregation to keep lay people on the sidelines.

The next area seems an attempt to make everyone welcome, but remember it is only the CDEs that can supervise and monitor the education and support. This means fewer CDEs doing actual DSME and DSMS. A number of studies have shown that a multidisciplinary team approach to diabetes care, education, and support works well for the patient. Yet in too many cases, the patient is often not the center of the efforts and central to the team approach.

“The disciplines that may be involved include, but are not limited to, physicians, psychologists and other mental health specialists, physical activity specialists (including physical therapists, occupational therapists, and exercise physiologists), optometrists, and podiatrists. More recently, health educators (e.g., Certified Health Education Specialists and Certified Medical Assistants), case managers, lay health and community workers, and peer counselors or educators have been shown to contribute effectively as part of the DSME team and in providing DSMS.”

Yes, they do include lay health and community workers plus peer counselors or educators when it is to their advantage. But, notice that a system must be in place that ensures supervision of these lay people. I agree that for questions the lay people do not have answers for need to have professionals available to answer when the questions are beyond their training. This is wise even for the CDEs to have doctors or other professionals available to back them up, but this seems to be an insult to their credentials.

This information is from the National Standards for DSME and DSMS.

National Standards for DSME and DSMS – Part 2

Part 2 of 6 Parts

In this blog, I will start with the standard number one and cover several of them. However, the definitions should be stated first and I will quote them.

DSME (Diabetes Self-Management Education).

“The ongoing process of facilitating the knowledge, skill, and ability necessary for prediabetes and diabetes self-care. This process incorporates the needs, goals, and life experiences of the person with diabetes or prediabetes and is guided by evidence-based standards. The overall objectives of DSME are to support informed decision making, self-care behaviors, problem solving, and active collaboration with the health care team and to improve clinical outcomes, health status, and quality of life.”

It is important to note that prediabetes is mentioned here and no distinction is made to prefer one type of diabetes over another. Yet, this distinction is prevalent in the activities of certified diabetes educators (CDEs) in practice today. This is the reason for calling attention to this.

DSMS (Diabetes Self-Management Support).

“Activities that assist the person with prediabetes or diabetes in implementing and sustaining the behaviors needed to manage his or her condition on an ongoing basis beyond or outside of formal self-management training. The type of support provided can be behavioral, educational, psychosocial, or clinical.”

These are the two key definitions that apply to this and several following blogs. Keep them in mind when reading the materials.

The first standard states, ”The provider(s) of DSME will document an organizational structure, mission statement, and goals. For those providers working within a larger organization, that organization will recognize and support quality DSME as an integral component of diabetes care.”

This is a powerful standard in any profession, but from practical knowledge, this is the first standard violated by most providers (CDEs). There are a few that do have this in place and do make use of it for the intended purpose. I am aware of one diabetes clinic in a Midwest city that has something like this on file and all new personnel are required to read this and agree with it before an interview even takes place. In addition, some of the literature handed out by the clinic includes parts of this document. CDEs that fall short of this or violate it are dismissed rather quickly. This is not my clinic, but one in a city about three hours distant depending on the traffic.

Another clinic also has a similar documentation, but this one was written by the doctors that own the diabetes clinic and it works very well. As to how it conforms to the above standard, I can only guess, but a relative of mine does say that she receives excellent education in all areas except nutrition. Since she is a retired nutritionist, she has learned not to include dietitians on her team.

The second standard states, “The provider(s) of DSME will seek ongoing input from external stakeholders and experts in order to promote program quality.”

This is a standard that depends on the office, clinic, or hospital. Some doctors prefer their input only, while others want their CDEs out in the community and participating in community meetings and after work activities. One primary care physician does have his CDEs involved with the school system and checking that pupils with diabetes are receiving proper care. When it was discovered that the school system had made a budget cut to eliminate the nurses, he went before the school board and warned them that they had better reinstate the cut or have the ADA investigating as well as the state board of education. It was reinstated at the next meeting and the two nurses rehired.

Some diabetes clinics do work to have input from the community and have proper channels for other input. I am not aware of any formal advisory boards, but they may exist and I don't know about them.

The third standard states, “The provider(s) of DSME will determine who to serve, how best to deliver diabetes education to that population, and what resources can provide ongoing support for that population.”

Ouch! It is no wonder there is widespread discrimination in the service provided. In many areas, this has to be the reason people with type 2 diabetes don't have CDEs available to them and receive no education about diabetes. Yes, even the standards authors recognize this and state, “Currently, the majority of people with diabetes and prediabetes do not receive any structured diabetes education.”

It is interesting the follow up statement the standards people make. Without the qualified people to be available, this just points out the fact that lay people need training to fill in gaps where CDEs are not available.

This information is from the National Standards for DSME and DSMS.

National Standards for DSME and DSMS – Part 1

Part 1 of 6 Parts

When I first started reading this, my thought was to bypass it and maybe consider this later, if at all. Something made me come back and read some parts, and ouch! I must say my wife was surprised and asked me what was making me roar with laughter. In reality, this is not funny, but the content and some of the ways they approach different parts do make me wonder.

It starts with the first paragraph. I see these numbers in most sources and can believe that they are realistic as estimates. The algorithms used probably make these numbers more accurate than we realize. Now is where the amusement starts.  The American Association of Diabetes Educators website formerly had listed memberships of about 13,000 members. They have now removed this number for whatever reason and a search of the site does not reveal the membership numbers.

With 18,800,000 people with diabetes and 13,000 CDEs (certified diabetes educators), this means that allotting one hour per patient would mean seeing 1,446 different patients per year and having 594 patients they could see twice a year. This is figured on a 2,040 hour work year and allowing 80 hours for vacation or two weeks. Now we know these numbers are not realistic as many patients are seen four times per year, or more. We don't know how many CDEs only work part-time, how many are not doing actual educator work, how many are retired, how many are in administration, and other numbers writing books and going on speaking tours. We know that most people with type 2 diabetes never even see a CDE, therefore we have to question if the CDE membership numbers are realistic. This says nothing about many rural areas of the USA where no CDEs live.

I did not include the seven million people that are estimated with undiagnosed diabetes because the CDEs would not be seeing them. Nor will I include any of the estimated 79 million people said to have elevated risk of type 2 diabetes. Then for the people on the “Task Force” for developing the standards to make this statement, “Diabetes self-management education (DSME) is a critical element of care for all people with diabetes and those at risk for developing the disease,” (bold is my emphasis) really makes me laugh as many CDEs do not even teach DSME. They seem to prefer mandates and mantras to doing an actual assessment and developing an education plan based on any assessment.

Until the AADE starts a division for peer-to-peer workers and peer mentors and gives them some of the skills needed, there will not be sufficient people to use DSME or give DSMS (diabetes self-management support) to the people with type 2 diabetes, much less those at risk for developing the disease. The standards have high ideals, but not the personnel to make them work. This is why I needed to laugh to avoid becoming angry.

When I read statements like this blog, and I have to agree with the sentiments expressed, and then along comes a comment like the first comment, it really points out the problems existing in our healthcare system. It also points out the problems in the CDE profession and their attitude about people with type 2 diabetes. I am not denying that people with type 1 diabetes may need more education and support than many people with type 2 diabetes. For people to say that endocrinologists should be exclusively for people with type 1 diabetes is not realistic. More people with type 2 diabetes are finding out that insulin works for them and has less side effects than many of the oral medications. They also need the education and support.

If you are concerned about peer-to-peer workers, peer mentors, and think I am pushing my own agenda, read this by the Standards Task Force.

“In the course of its work on the Standards, the Task Force identified areas in which there is currently an insufficient amount of research. In particular, there are three areas in which the Task Force recommends additional research:

1. What is the influence of organizational structure on the effectiveness of the provision of DSME and DSMS?

2. What is the impact of using a structured curriculum in DSME?

3. What training should be required for those community, lay, or peer workers without training in health or diabetes who are to participate in the provision of DSME and to provide DSMS?”

Yes, this is one of my aims and I am happy to see the Task Force suggesting that it be researched. While it is being researched, it needs to be acted on now as the number of people developing diabetes will continue to grow and the numbers of CDEs is not growing at a pace to keep up.

As for research on the influence of organizational structure on the effectiveness of the provision of DSME and DSMS, all we need to do is look at what has happened with DSME in the past. The organizational structure may be there at the upper levels, but at the practicing levels, there is no support for it except from rare individuals. There is also little research and support for DSME for the elderly as many CDEs will not work with them and consider this a waste of time since these people are no longer contributors to society. I have written about this here and here. It will remain to be seen if they will consider the value many of these elderly people could contribute as peer workers. Just don't hold your breath waiting for this to happen.

I would urge everyone to take the time to read the National Standards to be able to understand what may be possible. I would also encourage this so that if allowed, we are ready for an intelligent dialog and if denied this, as a way to hold the feet of the CDEs (including the AADE) to the fire. This may be only one of the ways we can break the exclusionary lock they presently have and are still very much trying to hold onto by keeping lay people out.

AACE/Takeda Webpage Taken Down

Like I had someone say to me, the American Association of Clinical Endocrinologists only cares about the image they can project and not what they can actually do for the patients or their own members. I thought this was a little harsh, but after what they have done with a page setup to promote reliable diabetes sources, only post 15 websites, and then pull it after a year, I can believe that. The image seems all important and if the image takes a hit, then pull the page.

However, bring in The American College of Endocrinology (ACE) to do the upkeep of the site, and it seems to last longer. Two such examples are this group of pages and these pages. How long these will stay in place remains to be seen. To be honest, I had not expected these to be there as there are no links to either from the AACE home page.

It is not surprising that some pages are dropped so rapidly by professional organizations, but the page that the AACE dropped could have been useful to endocrinologists and other physicians for materials to be used in handouts. This shows that it was basically lip service and the experts were not interested in approving more sites that could have been helpful to professionals and patients.

Even I had not anticipated the page being dropped so rapidly. Therefore, with the help of my readers, I would like to start collecting reliable diabetes sites for a blog listing. Then at least once a year, update that blog with new listings and republish. We need to start with the ADA (American Diabetes Association) even though many do not follow ADA, but we need to be aware of the guidelines they issue and other pages that may be of value.

At present, I am thinking a listing of sites that are good for all types of diabetes, a list that are good for type 1 diabetes, a list that are good for type 2 diabetes, and maybe a list for the other official types of diabetes as defined by the ADA. 

AADE Blog on BG Monitoring

If only this could be true! This blog by Carla Cox on the American Association of Diabetes Educators (AADE) website is the most positive blog about the supposed changes made by the American Diabetes Association (ADA) 2013 Guidelines. As research has shown by my blog here, 2013 may not be the year for much change, but maybe some of the results will be heard by the people at ADA and maybe for 2014, we will see some real change in the language and action by the insurance companies.

This quote from her blog is somewhat gratifying, “Benefits of monitoring have not been consistently demonstrated when patients with type 2 diabetes are on lifestyle-controlled regimens or oral medications (The Diabetes Educator, 2007; Health Technology Assess, 2009). Data aside, I believe all of us have seen how much patients learn about their BG response to meals, exercise and environmental pressure when checking BG values throughout the day, regardless of whether it’s controlled via lifestyle or medication. This is with the caveat, of course, that they understand how to interpret the results.”

It seems that the author is calling for more testing by type 2 people and education is what is needed. I could almost believe the good intentions, if certified diabetes educators (CDEs) were working heavily with type 2 patients. We know this isn't happening because there are not enough CDEs for this to become a reality. CDEs currently have no incentive to work with type 2 patients, as being reimbursed is a problem.

Even their own practice advisories from 2010 found at this link under 2010 says the following - “Shared medical appointments (SMA) are a healthcare practice approach that provides more access to patients while using existing resources. SMA are a recognized approach that have been shown to provide high quality care at reduce costs. While insurers may recognize these as separately reimbursable appointments, Medicare has yet to provide guidance on the topic.”  You will need to download the "Shared medical appointment" advisory with Adobe Reader (or another PDF viewer) to view it.

With many type 2 patients being under Medicare, I can understand that they do not wish to take on groups of people with type 2 diabetes as part of SMAs. Not all insurance companies are on board with reimbursing for patients not yet on Medicare. Therefore, in the meantime they will need to contact providers to see if they cover this. Most CDEs are not interested in contacting a variety of providers, as they would prefer a one on one situation. Yet, with the current shortage of CDEs, something needs to change. This says nothing about the needs of people in the “at risk” category (prediabetes) that receive no help.

Another factor that makes me question the sincerity of statements made by CDEs if the fact that Medicare is moving to more preventive medicine and this would seem to be the time for AADE to lobby the Centers for Medicare and Medicaid Services (CMS) to reimburse for SMAs as this could be a giant step forward to educating groups of people with type 2 diabetes and even many in the “at risk” group. Then for the enterprising CDEs, telemedicine may open up doors for education as well. Unless AADE attempts to open these avenues and pressure CMS to reimburse for these avenues, all I can say is the “feel good” hype is worse than BS, and I'm not talking blood sugar.

I sincerely wish this statement could be relied on and trusted - “Blood glucose monitoring is a cornerstone of diabetes education. Blood sugars shift throughout the day and often get progressively higher over time even in the “best” patient with type 2 diabetes.” The bold is my emphasis. I know from experience that this statement sounds good, but when mandates take place instead of education, it ruins the experience for most patients with type 2 diabetes.

This statement in the last paragraph of her blog gets my hackles up, “As diabetes educators, we are the “go to” persons to help guide patients to understand their BG results and to learn to act on the results to help normalize blood sugars and reduce risks associated with frequent BG values that are out of range.” But, how can we “go to” CDEs when they are not available and most don’t deal with type 2 diabetes people. I have to question where the CDEs are and why I should not consider statements like this, “feel good” hype?