Top

Current Diabetes Reports

Published in:

01-11-2019 | Care | Economics and Policy in Diabetes (AA Baig and N Laiteerapong, Section Editors)

Financing Diabetes Care in the U.S. Health System: Payment Innovations for Addressing the Medical and Social Determinants of Health

Authors: Loren Saulsberry, Monica Peek

Published in: Current Diabetes Reports | Issue 11/2019

Abstract

Purpose of Review

Review innovations in health care financing promoting health system investments in addressing medical and social determinants of health (SDH) for patients with diabetes.

Recent Findings

Particular payment models implemented in the public and private sectors increasingly offer flexibility in health care organizations (HCOs) to allocate resources towards helping patients with diabetes overcome the medical and socio-economic problems driving poor population and individual health.

Summary

The barriers imposed by the traditional fee-for-service (FFS) payment model to incorporating SDH into health care delivery across the health system are being overcome with new payment approaches rewarding the quality of care provided rather than strictly the volume of health services rendered. Evidence suggests health care financing changes will facilitate the realization of health reform goals to provide the right care to the right people at the right time through the expansion of the role of integrated care teams that can address patients’ medical and health-related social needs.

Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759–69. https://doi.org/10.1377/hlthaff.27.3.759.CrossRef

The Patient Protection and Affordable Care Act (PPACA), Pub. L. No. 111–148, 124 Stat. 119 (March 23, 2010). https://www.hhs.gov/healthcare/about-the-aca/index.html. Accessed August 1, 2019.

Martin AB, Hartman M, Washington B, Catlin A. National Health Care Spending in 2017: growth slows to post-great recession rates; share of GDP stabilizes. Health Aff (Millwood). 2017;38(1):96–106.

Waters H, Graf M. The Cost of Chronic Diseases in the U.S. Executive Summary. Milken Institute. May 2018. https://assets1b.milkeninstitute.org/assets/Publication/Viewpoint/PDF/Chronic-Disease-Executive-Summary-r2.pdf. Accessed August 1, 2019.

Centers for Disease Control and Prevention (CDC). About chronic diseases. 2019. https://www.cdc.gov/chronicdisease/about/index.htm. Accessed August 1, 2019.

Rowley WR, Bezold C, Arikan Y, Byrne E, Krohe S. Diabetes 2030: insights from yesterday, today, and future trends. Population Health Management. 2017;20(1):6–12. https://doi.org/10.1089/pop.2015.0181.CrossRefPubMedPubMedCentral

Centers for Disease Control and Prevention (CDC). National Diabetes Statistics Report, 2017. https://www.cdc.gov/diabetes/data/statistics/statistics-report.html. Accessed August 1, 2019.

Centers for Disease Control and Prevention (CDC). Diabetes and prediabetes. 2019. https://www.cdc.gov/chronicdisease/resources/publications/factsheets/diabetes-prediabetes.htm. Accessed August 1, 2019.

Kindig D, Stoddart G. What is population health? Am J Public Health. 2003;93(3):380–3. https://doi.org/10.2105/ajph.93.3.380.CrossRefPubMedPubMedCentral

10.

Lynn J, Straube BM, Bell KM, Jencks SF, Kambic RT. Using population segmentation to provide better health care for all: the “bridges to health” model. Milbank Quarter. 2007;85(2):185–208.CrossRef

11.

Marmot M. Social determinants of health inequalities. Lancet. 2005;365(9464):1099–104. https://doi.org/10.1016/S0140-6736(05)71146-6.CrossRefPubMed

12.

Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. In: Smedley BD, Stith AY, Nelson AR, editors. Unequal treatment: confronting racial and ethnic disparities in health care. Washington (DC): National Academies Press (US); 2003. https://www.ncbi.nlm.nih.gov/books/NBK220358/doi: https://doi.org/10.17226/12875.

13.

House JS. Social determinants and disparities in health: their crucifixion, resurrection, and ultimate triumph(?) in health policy. J Health Polit Policy Law. 2016;41(4):599–626. https://doi.org/10.1215/03616878-3620845.CrossRefPubMed

14.

Robert Wood Johnson Foundation (RWJF). 2014 Rankings; Key Findings Report. County Health Rankings & Roadmaps. http://www.countyhealthrankings.org/sites/default/files/2014%20County%20Health%20Rankings%20Key%20Findings.pdf. Accessed August 1, 2019.

15.

World Health Organization. “About Social Determinants of Health.” http://www.who.int/social_determinants/sdh_definition/en/. Accessed August 1, 2019.

16.

Artiga S, Hinton E. Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity. Kaiser Family Foundation. 2018. https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/. Accessed August 1, 2019.

17.

Pruitt Z, Emechebe N, Quast T, Taylor P, Byrant K. Expenditure reductions associated with a social service referral program. Popul Health Manag. 2018;21(6):469–76. https://doi.org/10.1089/pop.2017.0199.CrossRefPubMedPubMedCentral

18.

Daniel H, Bornstein SS, Kane GC, for the health and public policy Committee of the American College of Physicians. Addressing Social Determinants to Improve Patient Care and Promote Health Equity: An American College of Physicians Position Paper. Ann Intern Med. 2018;168:577–8. https://doi.org/10.7326/M17-2441.CrossRefPubMed

19.

American Academy of Family Physicians. Advancing health equity: principles to address the social determinants of health in alternative payment models. www.aafp.org/about/policies/all/socialdeterminants-paymentmodels.html. Accessed August 1, 2019.

20.

•• Castrucci B, Auerbach J. Meeting individual social needs falls short of addressing social determinants of health. Health Affairs Blog. 2019. https://doi.org/10.1377/hblog20190115.234942. Emphasizes the need for social and economic interventions at both the community and individual levels to comprehensively address social determinants of health.

21.

Kaiser Family Foundation. An overview of Medicare. 2019. https://www.kff.org/medicare/issue-brief/an-overview-of-medicare/. Accessed August 1, 2019.

22.

Rudowitz R, Garfield R, Hinton E. 10 things to know about Medicaid: setting the facts straight. Kaiser Family Foundation 2019. https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid-setting-the-facts-straight/. Accessed August 1, 2019.

23.

Berwick DM. Launching accountable care organizations—the proposed rule for the Medicare shared savings program. N Engl J Med. 2011;364(16):e32.CrossRef

24.

Centers for Medicare & Medicaid Services (CMS). Shared Savings Program. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/about.html. Accessed August 1, 2019.

25.

Fraze TK, Lewis VA, Tierney E, Colla CH. Quality of care improves for patients with diabetes in Medicare shared savings accountable care organizations: organizational characteristics associated with performance. Popul Health Manag. 2018;21(5):401–8.CrossRef

26.

• Malley AS, Rick EC, Sarwar R, Schultz E, Warren WC, Shah T, Abrams MK. How accountable care organizations use population segmentation to care for high-need, high-cost patients. The Commonwealth Fund. 2019. https://www.commonwealthfund.org/publications/issue-briefs/2019/jan/how-acos-use-segmentation-high-need-high-cost. Accessed August 1, 2019. Population segmentation of high need, high risk, or vulnerable patients may provide one way to enhance the care for patients with diabetes, ensuring their medical and social needs can be met.

27.

The CMS Innovation Center. https://innovation.cms.gov/; KFF. “What is CMMI?” and 11 other FAQs about the CMS Innovation Center. 2018. https://www.kff.org/medicare/fact-sheet/what-is-cmmi-and-11-other-faqs-about-the-cms-innovation-center/. Accessed August 1, 2019.

28.

Rich E, Lipson D, Libersky J, Parchman M. U.S. Department of Health & human services (HHS). Agency for Healthcare Research and Quality (AHRQ). Coordinating Care for Adults with Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions https://pcmh.ahrq.gov/page/coordinating-care-adults-complex-care-needs-patient-centered-medical-home-challenges-and. Accessed August 1, 2019.

29.

Centers for Medicare & Medicaid Services (CMS). Accountable health communities model. https://innovation.cms.gov/initiatives/ahcm. Accessed August 1, 2019.

30.

Van Vleet A, Paradise J. The State Innovation Models (SIM) Program: An overview. Kaiser Family Foundation. 2014. https://www.kff.org/medicaid/fact-sheet/the-state-innovation-models-sim-program-an-overview/. Accessed August 1, 2019.

31.

Kaiser Family Foundation. The State Innovation Models (SIM) Program: a look at round 2 grantees. 2015. https://www.kff.org/medicaid/fact-sheet/the-state-innovation-models-sim-program-a-look-at-round-2-grantees/. Accessed August 1, 2019.

32.

Taylor L. Housing and health: an overview of the literature. Health Affairs Health Policy Brief. 2018. https://doi.org/10.1377/hpb20180313.396577.

33.

McConnell KJ, Renfro S, Chan BK, Meath TH, Mendelson A, Cohen D, et al. Early performance in Medicaid accountable care organizations: a comparison of Oregon and Colorado. JAMA Intern Med. 2017;177(4):538–45. https://doi.org/10.1001/jamainternmed.2016.9098.CrossRefPubMedPubMedCentral

34.

Magnan, S. 2017. Social determinants of health 101 for health care: five plus five. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. doi: https://doi.org/10.31478/201710c.

35.

Berchick ER, Hood E, Barnett JC. Health insurance coverage in the United States: 2017. Current Population Reports. United States Census Bureau. 2018. https://www.census.gov/content/dam/Census/library/publications/2018/demo/p60-264.pdf. Accessed August 1, 2019.

36.

Japsen B. To keep you healthy, health insurers may soon pay your rent. August 14, 2018. Forbes. https://www.forbes.com/sites/brucejapsen/2018/08/14/to-keep-you-healthy-health-insurers-may-soon-pay-your-rent/#43b3608c67ce.

37.

Loprest P, Nightingale D. The nature of work and the social safety net. Urban Institute. July 2018. https://www.urban.org/research/publication/nature-work-and-social-safety-net. Accessed September 9, 2019.

38.

Hacker J. Divided welfare state: the battle over public and private social benefits in the United States. Cambridge: Cambridge University Press; 2002. https://doi.org/10.1017/CBO9780511817298.CrossRef

39.

• Iovan S, Lantz PM, Shapiro S. “Pay for success” projects: financing interventions that address social determinants of health in 20 countries. Am J Public Health. 2018;108(11):1473–7. Under the Pay for Success financing model, private entities offer upfront capital so that needed interventions can be implemented and scaled much faster with little to no risk to taxpayers. CrossRef

40.

Solar O, Irwin A. A conceptual framework for action on the social determinants of health: discussion paper for the commission on social determinants of health. 2007. https://www.who.int/social_determinants/publications/9789241500852/en/. Accessed August 1, 2019.

41.

“NKFM’s Diabetes Prevention Program to benefit from LISC funding to implement new Pay for Success program model.” National Kidney Foundation of Michigan. https://www.nkfm.org/about-us/news/nkfm%E2%80%99s-diabetes-prevention-program-benefit-lisc-funding-implement-new-pay-success. Accessed August 1, 2019.

42.

O’Malley AS, Rich EC, Sarwar R, Schultz E, Warren WC, Shah T, Abrams MK. How accountable care organizations use population segmentation to care for high need, High Cost Patients https://www.commonwealthfund.org/publications/issue-briefs/2019/jan/how-acos-use-segmentation-high-need-high-cost. Accessed August 1, 2019.

43.

Gottlieb L, Tobey R, Cantor J, Hessler D, Adler NE. Integrating social and medical data to improve population health: opportunities and barriers. Health Aff (Millwood). 2016;35(11):2116–23. https://doi.org/10.1377/hlthaff.2016.0723.CrossRef

44.

Olson DP, Oldfield BJ, Navarro SM. Standardizing social determinants of health assessments. Health Affairs Blog, March 18, 2019. https://www.healthaffairs.org/do/10.1377/hblog20190311.823116/full/. Accessed August 1, 2019.

45.

Friedman NL, Banegas MP. Toward addressing social determinants of health: a health care system strategy. Perm J. 2018;22:18–095. https://doi.org/10.7812/TPP/18-095.CrossRefPubMedCentral

46.

ICD-10-CM Official Guidelines for Coding and Reporting, FY 2019 from the Centers for Medicare and Medicaid Services (CMS). https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2019-ICD10-Coding-Guidelines-.pdf. Accessed August 1, 2019.

47.

Adler NE, Stead WW. Patients in context—EHR capture of social and behavioral determinants of health. N Engl J Med. 2015;372(8):698–701. https://doi.org/10.1056/NEJMp1413945.CrossRefPubMed

48.

Spencer A, Freda B, McGinnis T, Gottlieb L. Measuring social determinants of health among Medicaid beneficiaries: early state lessons. Centers for Healthcare Strategies Inc 2016. https://www.chcs.org/media/CHCS-SDOH-Measures-Brief_120716_FINAL.pdf. Accessed August 1, 2019.

49.

“UnitedHealthcare and the AMA Collaborate to Understand and Address Social Barriers Preventing People’s Access to Better Health.” 2 Apr 2019. https://newsroom.uhc.com/content/uhc/newsroom/news-releases/AMA-announcement.html. Accessed August 1, 2019.

50.

Japsen B. “AMA Backs UnitedHealth’s Billing Codes For Social Determinants of Health.” 2 Apr 2019. https://www.forbes.com/sites/brucejapsen/2019/04/02/ama-backs-unitedhealths-billing-codes-for-social-determinants-of-health/#2a1dac9a2204. .

51.

Saulsberry L, Seo V, Fung V. The impact of changes in medicaid provider fees on provider participation and enrollees’ care: a systematic literature review. J Gen Intern Med. 2019. https://doi.org/10.1007/s11606-019-05160-x.CrossRef

52.

Russell LB. Preventing chronic disease: an important investment, but Don’t count on cost savings. Health Aff. 2009;28(1):42–5. https://doi.org/10.1377/hlthaff.28.1.42.CrossRef

Title: Financing Diabetes Care in the U.S. Health System: Payment Innovations for Addressing the Medical and Social Determinants of Health
Authors: Loren Saulsberry
Monica Peek
Publication date: 01-11-2019
Publisher: Springer US
Keyword: Care
Published in: Current Diabetes Reports / Issue 11/2019
Print ISSN: 1534-4827
Electronic ISSN: 1539-0829
DOI: https://doi.org/10.1007/s11892-019-1275-6

Live Webinar | 27-06-2024 | 18:00 (CEST)

Keynote webinar | Spotlight on medication adherence

Reserve your place

Live: Thursday 27th June 2024, 18:00-19:30 (CEST)

WHO estimates that half of all patients worldwide are non-adherent to their prescribed medication. The consequences of poor adherence can be catastrophic, on both the individual and population level.

Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.

Prof. Kevin Dolgin

Prof. Florian Limbourg

Prof. Anoop Chauhan

Developed by: Springer Medicine

Obesity Clinical Trial Summary

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.

Developed by: Springer Medicine

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose of Review

Recent Findings

Summary

Please log in to get access to this content

Other articles of this Issue 11/2019

Pregnancy and Gestational Diabetes Mellitus (GDM) in North American Indian Adolescents and Young Adults (AYA): Implications for Girls and Stopping GDM

USA Vs Europe: Who Is Leading the Diabetes Tech Race?

A Practice in Maturation: Current Perspectives on the Transition from Pediatric to Adult Care for Young Adults with Diabetes

Emerging Concepts in the Treatment of Diabetic Retinopathy

Risk of Type 1 Diabetes in the Offspring Born through Elective or Non-elective Caesarean Section in Comparison to Vaginal Delivery: a Meta-Analysis of Observational Studies

Benefit-to-Risk Balance of Weight Loss Interventions in Older Adults with Obesity

Keynote webinar | Spotlight on medication adherence

Live: Thursday 27th June 2024, 18:00-19:30 (CEST)

At a glance: The STEP trials