Shortcomings in Public and Private Insurance Coverage of Diabetes Self-Management Education and Support

Abstract

The objective of this study is to present preliminary data to characterize public and private insurance coverage for diabetes self-management education (DSM Education) and diabetes self-management support (DSM Support). Representatives from Medicaid and 2 private insurance providers in 10 states provided coverage information for their insurance plans. Two states (the most populous state from the East and West coasts) were sampled purposively and 8 additional states from 4 geographic regions (northeast, southeast, northwest, southwest) were sampled at random. Representatives from each private insurer described both a premium and basic coverage plan. Thus, 10 Medicaid programs and 40 private insurance plans were represented. Information about Medicare coverage was accessed from publicly available documents. Restricted by physician certification of patient eligibility, Medicare coverage included 10 hours of DSM Education plus 3 hours of medical nutrition therapy (MNT) within a continuous 12-month period, and 4 hours of follow-up (2 hours DSM Education and 2 hours MNT) for each subsequent year. Only 22 of 40 sampled private insurance and 5 of 10 Medicaid plans covered DSM Education, which ranged from 7 to 20 hours of education per year. Medicaid and private plans often limited the amount of DSM Education or required patients to obtain a physician certification of eligibility. Other than on-demand access features, coverage of DSM Support was minimal. Public and private insurance coverage of DSM Education was neither widespread nor uniform, while coverage of DSM Support was scarce. (Population Health Management 2012;15:144–148)

Introduction

A ccording to the American Diabetes Association (ADA), the number of Americans living with diabetes is expected to almost double, from 23 million to 44 million, over the next 25 years.¹ This increase in diabetes prevalence likely will strain the resources of the US health care system, given that the 2007 health care costs of managing diabetes totaled $116 billion, with approximately half of that amount spent on hospital care for largely preventable diabetes-related complications.¹

Recognizing the importance of preventing costly diabetes-related hospital admissions and complications, the ADA, the American Association of Diabetes Educators, and other professional organizations set national standards calling for the routine availability of Diabetes Self-Management Education (DSM Education).² These standards reflect substantial evidence that DSM Education is a cost-effective means³ to achieve benefits in quality of life and improvement in key health indicators such as glycated hemoglobin.^3

–9 Additionally, the standards are in line with the Healthy People 2010 goal to increase the percentage of people receiving DSM Education from 40% to 60%.¹⁰ Although critical, DSM Education is not sufficient to sustain diabetes self-care,¹¹ as initial improvements in health outcomes often diminish after 6 months.⁹

Both the National Standards for Diabetes Self-Management Education² and the Robert Wood Johnson Foundation Diabetes Initiative^12,13 recognize that, in addition to DSM Education, individuals need diabetes self-management support (DSM Support), defined as “activities to assist individuals with implementing and sustaining the ongoing behaviors needed to manage their illness …,” including “… behavioral, educational, psychosocial, or clinical …” support.² Many strategies are available to deliver education and support, including online and personal health coaching.^14,15

This article presents preliminary data about public and private insurance coverage of DSM Education and DSM Support. Because 46 states have legislation requiring insurance companies to offer coverage for DSM Education,¹⁶ we anticipated that DSM Education would be fairly well covered by both public and private plans. Alternatively, we hypothesized that insurance coverage for DSM Support would be more limited because the importance of DSM Support to maintaining health was established relatively recently and evidence of its cost-effectiveness is more limited.

Methods

We used qualitative methods to gather information for this study. For Medicare, we performed a document review of coverage information from the Centers for Medicare and Medicaid Services Web page (http://www.cms.hhs.gov/DiabetesSelfManagement/02_ProvResources.asp). For private insurance and Medicaid, we gathered information through key informant interviews with insurance representatives from 10 states. We sampled the most populous state from the East and West coasts and randomly sampled 8 additional states from 4 geographic regions: 2 each from the southeast, northeast, northwest, and southwest. In each region, one of the 2 sampled states was randomly selected from among those below the median state population for the region and the other was selected from among those above the median.

For each state, we conducted key informant interviews with representatives from Medicaid, as well as with 2 private insurance providers, which were identified from state-specific lists of health insurance companies (www.ehealthinsurance.com). We selected private companies that were available by phone and sought to avoid oversampling any single insurer. Contact information for each company was obtained from the company's Web site. Automated telephone directories generally identified the appropriate person to answer questions about “diabetes insurance coverage.” The caller presented herself as inquiring on behalf of her uninsured father, explaining that he had diabetes and needed coverage. This was not our original data collection strategy. However, private insurance companies refused our attempts to obtain coverage information for existing plans, requiring valid member identification or claims codes to provide such information. Thus, we used the strategy described.

Private insurance representatives were either sales associates or, in 2 cases, directed the company's diabetes program in that state. Medicaid representatives varied from bureau chiefs to program managers. For private insurers, the key informant was asked to provide coverage information for both a premium and a basic commercial coverage plan. We sampled a total of 10 Medicaid programs and 40 private insurance plans (2 premium and 2 basic plans in each state).

Coverage for DSM Education was our main variable of interest. This was defined as self-management education (eg, instruction in glucose and symptom monitoring, proper exercise and diet, medications) provided in a class or individual format by a health professional such as a physician, nurse, certified diabetes educator (CDE), or registered dietitian (RD). Additionally, key informants described coverage for DSM Support (Table 1).

Table 1.

Key Informant Interview Questions for Diabetes Self-Management Education (DSM Education) and Support (DSM Support)

Domain	Interview Questions
DSM Education	Does your plan provide coverage for diabetes self-management education classes or sessions with health professionals such as a CDE or RD?^a
DSM Support
Ongoing personal relationship with health professional	Does your plan promote ongoing contact with a RD, CDE, or other nonphysician health professional?
On-demand access for health questions	Does your plan provide diabetes patients with on-demand access for health questions, such as a 24/7 nurse hotline?
Proactive contact from a health professional	Does your plan promote proactive contact from a health professional, such as calling or mailing patients?
Varied channels for diabetes information	Does your plan provide patients with access to diabetes information in multiple formats, such as classes, written materials, and Web sites, for example?
Referral to community resources	Does your plan refer diabetes patients to community resources, such as support groups, safe places to exercise, or healthy cooking classes, for example?

For representatives who were unsure of what self-management education meant, we further explained that it would include education about blood glucose monitoring, medications, proper exercise and diet, and stress management.

CDE, certified diabetes educator; RD, registered dietitian.

Results

Diabetes self-management education

Medicare coverage

Medicare covered 10 hours of initial self-management training within a continuous 12-month period; 1 hour of one-to-one education, and 9 hours of group format education accredited by the ADA, the American Association of Diabetes Educators, or Indian Health Services. Additionally, Medicare covered 3 hours of medical nutrition therapy (MNT) with an RD or other nutrition professional during the initial year of eligibility. Beneficiaries were eligible for DSM Education if they: (a) were newly diagnosed with diabetes; (b) began taking diabetes medications for the first time; or (c) were at risk for diabetes complications. All benefits required physician certification of patient eligibility.

Table 2 presents the number of sampled basic and premium private insurance plans, as well as Medicaid programs that reported specific features of DSM Education and DSM Support.

Table 2.

Number of Sampled Private Insurance and Medicaid Plans Reporting Specific Features of Coverage for DSM Education and DSM Support

	Private Plans		Medicaid Plans
	Premium N of 20 (%)	Basic N of 20 (%)	N of 10 (%)
DSM Education	11 (55%)	11 (55%)	5 (50%)
Access
Unlimited access to DSM Education with co-pay	4	4	0
Restricted access to DSM Education	7	7	5
Educational format
Group DSM Education^a	–	–	2
Individual DSM Education with RD or CDE^a	–	–	1
Both group and individual education^a	–	–	2
DSM Support
Ongoing personal relationship with health professional	4 (20%)	2 (10%)	4 (40%)
On-demand access for health questions	18 (90%)	17 (85%)	1 (10%)
24/7 nurse hotlines	10	10	0
Phone lines, limited hours	1	1	1
Online chat	7	6	0
Proactive contact from a health professional	5 (25%)	3 (15%)	0 (0%)
Mailed appointment reminders	1	1	0
Varied channels for diabetes information	8 (40%)	8 (40%)	1 (10%)
Referral to community resources	10 (50%)	8 (40%)	4 (40%)
Support group referrals	8	8	3
Other resource referrals	8	7	4

Percentages of plans reporting major categories of coverage area in parentheses.

Private insurance plan representatives were unable to clarify format of DSM Education among group, individual, or mixed formats.

CDE, certified diabetes educator; DSM Education, diabetes self-management education; DSM Support, diabetes self-management support; RD, registered dietitian.

DSM Education was covered by 55% of private insurance plans and 50% of Medicaid plans. Many private plans restricted the number of hours covered (for example, through spending caps ranging from $250 to $400/year per individual) and/or required a physician certification of eligibility to participate. In contrast, 8 plans covered unlimited education but required co-pay for each session.

All 5 Medicaid plans that covered DSM Education restricted the amount of coverage, ranging from 7 to 20 hours for the initial year of eligibility, and/or limited coverage to newly-diagnosed individuals or those with physician certification for significant changes in health status.

Diabetes self-management support

Medicare coverage

Medicare covered 2 hours of follow-up DSM Education and 2 hours of MNT therapy for each subsequent year after the initial year of eligibility. As with DSM Education, this coverage was contingent on physician certification of patient eligibility. Other than these 4 hours per year of ongoing education with health professionals, Medicare did not cover any other type of DSM Support.

Ongoing personal relationship with a health professional

Contingent on physician certification of patient eligibility, 4/10 Medicaid plans provided limited follow-up (1–5 hours/year) with an RD or other health professional. Among private plans, 6/40 offered telephone follow-up by a RD, registered nurse (RN), or CDE but only for a period of several months as extensions of DSM Education programs.

On-demand access for health questions

Although most private insurance plans provided on-demand access for health questions, this type of support was rare among Medicaid plans. “24/7” nurse hotlines were the most common form of on-demand access, followed by online chat resources and information lines during regular business hours.

Proactive contact from a health professional

Among all 50 Medicaid and private plans surveyed, only 8 offered some form of proactive contact by telephone or mail.

Varied channels for diabetes information

Among private plans, 40% offered self-management information through multiple channels. However, channels offered were generally inexpensive and low intensity, such as Web sites and printed materials. In most cases, such contacts were offered in addition to DSM Education classes. The 2 private plans that did not offer DSM Education classes qualified as meeting this criterion because they offered a variety of low-intensity services (eg, information on Web sites, mailing of written educational materials) instead of DSM Education classes. Only 1 Medicaid plan met this criterion via a resource guide developed in collaboration with its Centers for Disease Control and Prevention-supported state diabetes prevention and control program.

Referrals to community resources

Less than half of private and Medicaid plans directly referred patients to community resources (eg, support groups) or other resources (eg, safe places to exercise). One private plan offered a Web site search function that generated a list of local gyms and weight loss programs in members' zip codes for which patients could receive discounts. Also, 1 Medicaid plan provided patients with a community resource guide.

Discussion

Only 50% of Medicaid and 55% of sampled private insurance plans offered coverage for DSM Education. Medicare's DSM Education coverage was limited in amount (13 hours for the initial year and 4 hours for each subsequent year) and accessibility (all services requiring physician certification of patient eligibility). Medicaid's coverage ranged from 0 to 20 hours of education per year and often was restricted (eg, recent diagnosis or health status change certified by physician). Private plans often restricted how much a patient could participate (eg, spending caps).

With the exception of on-demand access to health professionals via 24/7 nurse hotlines, coverage for DSM Support was lacking. Ongoing relationships with nonphysician health professionals, such as an RN or RD, and proactive contact from health professionals were least likely to be covered by insurance plans. Given increased acceptance of the patient-centered medical home and personal and online health coaching, we expect to see greater coverage of these types of support-focused interventions in the future.

It appears that Medicare's physician certification requirement to receive benefits was emulated by many of the state Medicaid programs. Counter to national calls to encourage DSM Education for individuals who may benefit from it, physician certification of patient eligibility may act as a barrier to participation in DSM Education programs. For example, a recent article by Ruppert and colleagues¹⁷ found that, despite efforts to increase patient and physician awareness of a DSM Education program, 76% of rural diabetes patients were not referred by their providers for DSM Education. Moreover, an analysis of Medicare's reimbursement records for 2004–2005 indicated that “only 1% of Medicare beneficiaries with diabetes received” diabetes self-management training.¹⁸ Other reports estimate that 60%–70% of patients with diabetes have not received self-management interventions.¹⁹ In this context, the restriction on DSM Education and Support posed by requirements such as physician certification could restrict access to self-management training rather than promote it. Future studies should document whether the ways in which insurers cover DSM Education programs (eg, cover physician education of patients through procedure and training codes versus offering education and support through health plan staff ) hinder or facilitate patient access to DSM Education programs.

As mentioned previously, our original plan was to contact the most knowledgeable representative at each insurance company to obtain descriptions of covered services. However, private insurance representatives would not describe coverage and benefits for existing members without a member identification number or claims code. Thus, we relied on an interviewer who represented herself as inquiring on behalf of an uninsured father with diabetes, which leads to several qualifications of the study findings. First, the sales representatives contacted by the interviewer may not have provided completely accurate or thorough information. Second, the services described as available for an uninsured adult male who already has diabetes may not be typical of services offered to other types of patients (eg, to a member of a covered employee group who develops diabetes).

In addition to these general limitations, the generality of the findings may be influenced by the ways in which DSM Education and Support benefits were defined. Specifically, our ability to directly compare different insurance plans is limited by the fact that insurers may define “coverage” and “benefits” differently. Also, we did not ask representatives whether benefits were offered to all patients or only to targeted groups of patients such as those at high risk for hospitalization. Thus, it is possible that our results may not reflect more extensive services that insurers provide to such “high-risk” subgroups. Additionally, the results may underestimate patient access to DSM Education and Support when services are offered through channels such as employers contracting with wellness and care management vendors. Such services would not be reported by insurers as covered benefits.

Additional limitations include the number of insurance companies and plans surveyed and the possibility that they may not represent the broader range of insurers in the United States. We also recognize that classifying plans as basic and premium is an oversimplification because the benefits packages offered vary greatly, numbering perhaps in the thousands even for single insurance companies. Our sampling scheme did not allow us to capture this type of variability in benefits.

The variability among plans and inability to characterize coverage for DSM Education and Support may be limitations of the study, but they also represent very real challenges for those trying to gain access to important services. Indeed, these limitations highlight the very unsystematic provision of diabetes self-management services in the US health care system. Although the estimates reported here may not fully capture the details of provision and coverage, the broad picture they portray seems clear: DSM Education and Support remain sharply limited in the United States despite the fact that they have been linked to improved patient outcomes and that national guidelines and state policies call for their availability to all with diabetes.

Footnotes

Author Disclosure Statement

Drs. Carpenter, Fisher, and Greene disclosed no conflicts of interest.

Preparation of this article was supported by the Robert Wood Johnson Foundation through its Diabetes Initiative.

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