Skip to main content
  • More from ADA
    • Diabetes
    • Diabetes Care
    • Diabetes Spectrum
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
    • ADA Scientific Sessions Abstracts
    • BMJ Open Diabetes Research & Care
  • Subscribe
  • Log in
  • My Cart
  • Follow ada on Twitter
  • RSS
  • Visit ada on Facebook
Clinical Diabetes

Advanced Search

Main menu

  • Home
  • Current
    • Current Issue
    • Online Ahead of Print
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Browse
    • Issue Archive
    • Saved Searches
    • COVID-19 Article Collection
    • Quality Improvement Sucess Stories
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Info
    • About the Journal
    • About the Editors
    • ADA Journal Policies
    • Instructions for Authors
  • Advertising
  • Reprints/Reuse
  • Subscriptions
    • Individual Subscriptions
    • Institutional Subscriptions and Site Licenses
    • Access Institutional Usage Reports
    • Purchase Single Issues
  • Alerts
    • E­mail Alerts
    • RSS Feeds
  • Podcasts
    • Diabetes Core Update
    • Special Podcast Series: Therapeutic Inertia
    • Special Podcast Series: Influenza Podcasts
    • Special Podcast Series: SGLT2 Inhibitors
    • Special Podcast Series: COVID-19
  • Submit
    • Submit a Manuscript
    • Submit Cover Art
    • Instructions for Authors
    • ADA Journal Policies
  • More from ADA
    • Diabetes
    • Diabetes Care
    • Diabetes Spectrum
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
    • ADA Scientific Sessions Abstracts
    • BMJ Open Diabetes Research & Care

User menu

  • Subscribe
  • Log in
  • My Cart

Search

  • Advanced search
Clinical Diabetes
  • Home
  • Current
    • Current Issue
    • Online Ahead of Print
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Browse
    • Issue Archive
    • Saved Searches
    • COVID-19 Article Collection
    • Quality Improvement Sucess Stories
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Info
    • About the Journal
    • About the Editors
    • ADA Journal Policies
    • Instructions for Authors
  • Advertising
  • Reprints/Reuse
  • Subscriptions
    • Individual Subscriptions
    • Institutional Subscriptions and Site Licenses
    • Access Institutional Usage Reports
    • Purchase Single Issues
  • Alerts
    • E­mail Alerts
    • RSS Feeds
  • Podcasts
    • Diabetes Core Update
    • Special Podcast Series: Therapeutic Inertia
    • Special Podcast Series: Influenza Podcasts
    • Special Podcast Series: SGLT2 Inhibitors
    • Special Podcast Series: COVID-19
  • Submit
    • Submit a Manuscript
    • Submit Cover Art
    • Instructions for Authors
    • ADA Journal Policies
Departments

Third-Party Reimbursement for Diabetes Care, Self-Management Education, and Supplies

  1. American Diabetes Association
    Clinical Diabetes 2003 Oct; 21(4): 183-184. https://doi.org/10.2337/diaclin.21.4.183
    PreviousNext
    • Article
    • Info & Metrics
    • PDF
    Loading

    Reprinted with permission from

    Diabetes Care 26 (Suppl. 1):S143–S144, 2003

    .

    Diabetes is a chronic disease that affects nearly 17 million Americans,1 with over 10 million cases diagnosed, and is characterized by serious, costly, and potentially fatal complications. The total cost of diagnosed cases of diabetes in the U.S. in 2002 was estimated to be $92 billion.1 To prevent or delay the costly complications and to enable people with diabetes to lead healthy, productive lives, appropriate medical care based on current standards of practice, self-management education, and medication and supplies must be available to everyone with diabetes. This paper is based on technical reviews titled “Diabetes Self-Management Education”2 and “National Standards for Diabetes Self-Management Education Programs.”3

    The goal of medical care for people with diabetes is to optimize glycemic control and minimize complications. The Diabetes Control and Complications Trial (DCCT) demonstrated that treatment that maintains blood glucose levels near normal in type 1 diabetes delays the onset and reduces the progression of microvascular complications. The U.K. Prospective Diabetes Study (UKPDS) documented that optimal glycemic control can also benefit most individuals with type 2 diabetes. To achieve optimal glucose control, the person with diabetes must be able to access health care providers who have expertise in the field of diabetes. Treatment plans must include self-management training, regular and timely laboratory evaluations, medical nutrition therapy, appropriately prescribed medication(s), and regular self-monitoring of blood glucose (SMBG) levels. The American Diabetes Association position statement “Standards of Medical Care for Patients with Diabetes Mellitus” outlines appropriate medical care for people with diabetes.4

    An integral component of the DCCT was self-management education (in-patient and/or outpatient) delivered by an interdisciplinary team. Self-management training also helps people with type 2 diabetes adjust their daily regimen to improve glycemic control. Diabetes self-management education is the process of providing the person with diabetes with the knowledge and skills to perform self-care on a day-to-day basis. Self-management education teaches the person with diabetes to assess the relationships among medical nutrition therapy, activity level, emotional and physical status, and medications and then respond appropriately and continually to those factors to achieve and maintain optimal glucose control.

    Today, self-management education is a critical part of the medical plan for people with diabetes, such that medical treatment of diabetes without systematic self-management education cannot be regarded as acceptable care. The National Standards for Diabetes Self-Management Education Programs establish specific criteria against which diabetes education programs can be measured, and a quality assurance program has been developed and subsequently revised.5

    Treatments and therapies that improve glycemic control and reduce the complications of diabetes will also significantly reduce health care costs.6,7 Numerous studies have demonstrated that self-management education leads to reductions in the costs associated with all types of diabetes. Participants in self-management education programs have been found to have decreased lower-extremity amputation rates, reduced medication costs, and fewer emergency room visits and hospitalizations.

    Access to the integral components of diabetes care, such as health care visits, diabetes supplies and medications, and self-management education, is essential. The American Diabetes Association believes insurers must reimburse for medical treatment and also for self-management education programs that have met accepted standards, such as the American Diabetes Association’s National Standards for Self-Management Education Programs. All medications and supplies, such as syringes, strips, and meters, related to the daily care of diabetes must also be reimbursed by third-party payers. Organizations that purchase health care benefits for their members or employees should insist that self-management education, medications, and supplies should be included in the services provided, and managed care organizations should include these services and supplies in the basic plan available to all participants.

    It is recognized that the use of formularies, prior authorization, and related provisions (hereafter referred to as “controls”), such as competitive bidding, can manage provider practices as well as costs to the potential benefit of payers and patients. Social Security Act Title XIX, section 1927, states that excluded agents should not have “a significant clinically meaningful therapeutic advantage in terms of safety, effectiveness or clinical outcomes of such treatment of such population.” A variety of laws, regulations, and executive orders also provide guidance on the use of such controls to oversee the purchase and use of durable medical equipment (hereafter referred to as “equipment”) and single-use medical supplies (hereafter referred to as “supplies”) associated with the management of diabetes. Consideration of certain principles should occur in creating and enforcing these controls that impact comprehensive medical needs of people living with type 1, type 2, or gestational diabetes.

    Reductions in hemoglobin A1c to ≤7% have been associated with improved outcomes and a reduction in the risk of diabetes-related complications. Outcome data are only available for animal source insulins, sulfonylureas, and metformin. Newer medications, blood glucose monitors, blood glucose test strips, insulin pumps, and related supplies, as well as other equipment and supplies associated with the use of these items, are expected to similarly reduce the risk of diabetic complications in proportion to glucose lowering. More than one agent is typically required to achieve glycemic targets, and the effect of multiple agents used in combination is additive. A variety of equipment and supplies are also necessary to manage diabetes and reach glycemic targets. Thus, any controls should ensure that all classes of antidiabetic agents with unique mechanisms of action are available to facilitate achieving glycemic goals to reduce the risk of complications. Similar issues operate in the management of lipid disorders, hypertension, and other cardiovascular risk factors, as well as for other diabetes complications. Furthermore, any controls should ensure that all classes of equipment and supplies designed for use with such equipment are available to facilitate achieving glycemic goals to reduce the risk of complications.

    The major limitation to achieving stringent glycemic targets is treatment-emergent hypoglycemia, which can be a significant safety issue limiting effectiveness of care and can on occasion result in serious morbidity and mortality. In patients with severe or frequent hypoglycemia or certain diabetes complications, some antidiabetic agents, equipment, and supplies are associated with lower risks of hypoglycemia at similar levels of overall control and should be available to special populations.

    Though it can seem appropriate for controls to restrict perceived items of convenience in chronic disease management, particularly with a complex disorder such as diabetes, it should be recognized that adherence is a major barrier to achieving targets. Any controls should take into account the huge burden of intensive insulin management on patients, particularly in the management of type 1 diabetes. Protections should ensure that patients with diabetes can comply with therapy in the widely variable circumstances encountered in daily life. These protections should guarantee access to an acceptable range and all classes of antidiabetic medications, equipment, and supplies. Furthermore, fair and reasonable appeals processes should ensure that diabetic patients and their medical care practitioners can obtain medications, equipment, and supplies that are not contained within existent controls.

    Diabetes management needs individualization in order for patients to reach glycemic targets. Because there is diversity in the manifestations of the disease and in the impact of other medical conditions upon diabetes, it is common that practitioners will need to uniquely tailor treatment for their patients. To reach diabetes treatment goals, practitioners should have access to all classes of anti-diabetic medications, equipment, and supplies without undue controls. Without appropriate safeguards, these controls could constitute an obstruction of effective care.

    The value of self-management education and provision of diabetes supplies has been acknowledged by the passage of the Balanced Budget Act of 19978 and by stated medical policy on both diabetes education9 and medical nutrition therapy.10

    Footnotes

    • American Diabetes Association

    References

    1. ↵
      Centers for Disease Control and Prevention. National Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the United States, 2000. Atlanta, GA, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2002
    2. ↵
      Clement S: Diabetes self-management education (Technical Review). Diabetes Care 18:1204–1214, 1995
      OpenUrlFREE Full Text
    3. ↵
      Funnell MM, Haas LB: National standards for diabetes self-management education programs (Technical Review). Diabetes Care 18:100–116, 1995
      OpenUrlFREE Full Text
    4. ↵
      American Diabetes Association: Standards of medical care for patients with diabetes mellitus (Position Statement). Diabetes Care 26 (Suppl. 1):S33–S50, 2003
    5. ↵
      American Diabetes Association: National standards for diabetes self-management education (Position Statement). Diabetes Care 26 (Suppl. 1):S149–S156, 2003
    6. ↵
      Herman WH, Dasbach DJ, Songer TJ, Thompson DE, Crofford OB: Assessing the impact of intensive insulin therapy on the health care system. Diabetes Rev 2:384–388, 1994
      OpenUrl
    7. ↵
      Wagner EH, Sandu N, Newton KM, McCullock DK, Ramsey SD, Grothaus LC: Effects of improved glycemic control on health care costs and utilization. JAMA 285:185–189, 2001
      OpenUrl
    8. ↵
      Balanced Budget Act of 1997. U.S. Govt. Printing Office, 1997, p. 115–116 (publ. no. 869-033-00034-1)
    9. ↵
      Diabetes outpatient self-management training services. Available from http://www.hcfa.gov/coverage
    10. ↵
      Duration and frequency of the medical nutrition therapy (MNT) benefit. Available from http://www.hcfa.gov/coverage
    View Abstract
    PreviousNext
    Back to top

    In this Issue

    October 2003, 21(4)
    • Table of Contents
    • Index by Author
    Sign up to receive current issue alerts
    View Selected Citations (0)
    Print
    Download PDF
    Article Alerts
    Sign In to Email Alerts with your Email Address
    Email Article

    Thank you for your interest in spreading the word about Clinical Diabetes.

    NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

    Enter multiple addresses on separate lines or separate them with commas.
    Third-Party Reimbursement for Diabetes Care, Self-Management Education, and Supplies
    (Your Name) has forwarded a page to you from Clinical Diabetes
    (Your Name) thought you would like to see this page from the Clinical Diabetes web site.
    CAPTCHA
    This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
    Citation Tools
    Third-Party Reimbursement for Diabetes Care, Self-Management Education, and Supplies
    Clinical Diabetes Oct 2003, 21 (4) 183-184; DOI: 10.2337/diaclin.21.4.183

    Citation Manager Formats

    • BibTeX
    • Bookends
    • EasyBib
    • EndNote (tagged)
    • EndNote 8 (xml)
    • Medlars
    • Mendeley
    • Papers
    • RefWorks Tagged
    • Ref Manager
    • RIS
    • Zotero
    Add to Selected Citations
    Share

    Third-Party Reimbursement for Diabetes Care, Self-Management Education, and Supplies
    Clinical Diabetes Oct 2003, 21 (4) 183-184; DOI: 10.2337/diaclin.21.4.183
    del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
    • Tweet Widget
    • Facebook Like
    • Google Plus One

    Jump to section

    • Article
      • Footnotes
      • References
    • Info & Metrics
    • PDF

    Related Articles

    Cited By...

    More in this TOC Section

    Departments

    • Case Reports on Diabetes-Related Outcomes for Pregnant Women in the National Diabetes Prevention Program
    • Transitioning to Fixed-Ratio Combination Therapy: Five Frequently Asked Questions Health Care Providers Should Anticipate From Their Patients
    • Gvoke HypoPen: An Auto-Injector Containing an Innovative, Liquid-Stable Glucagon Formulation for Use in Severe Acute Hypoglycemia
    Show more Departments

    Position Statement

    • Standards of Medical Care in Diabetes—2019 Abridged for Primary Care Providers
    • Standards of Medical Care in Diabetes—2018 Abridged for Primary Care Providers
    • Standards of Medical Care in Diabetes—2017 Abridged for Primary Care Providers
    Show more Position Statement

    Similar Articles

    Navigate

    • Current Issue
    • Papers in Press
    • Abridged Standards of Care
    • Archives
    • Submit
    • Subscribe
    • Email Alerts
    • RSS Feeds

    More Information

    • About the Journal
    • Instructions for Authors
    • Journal Policies
    • Reprints and Permissions
    • Advertising
    • Privacy Policy: ADA Journals
    • Copyright Notice/Public Access Policy
    • Contact Us

    Other ADA Resources

    • Diabetes
    • Diabetes Care
    • Diabetes Spectrum
    • Scientific Sessions Abstracts
    • Standards of Medical Care in Diabetes
    • BMJ Open - Diabetes Research & Care
    • Professional Books
    • Diabetes Forecast

     

    • DiabetesJournals.org
    • Diabetes Core Update
    • ADA's DiabetesPro
    • ADA Member Directory
    • Diabetes.org

    © 2021 by the American Diabetes Association. Clinical Diabetes Print ISSN: 0891-8929, Online ISSN: 1945-4953.