Does mandated diabetes coverage boost compliance?

Forty-six states now require insurers to cover things like glucose monitors, test strips, and self-management training. Not everyone approves.

By Wayne J. Guglielmo
Senior Editor

Eric J. Wedell is one of those doctors whose influence extends beyond the exam room. This year, the Cheyenne, WY, endocrinologist joined forces with a regional representative of the American Diabetes Association to push through the state's first diabetes benefits law. The legislation requires state-regulated individual and group insurers to provide coverage for things like blood glucose monitors and test strips, as well as for self-management training. "Studies show that giving patients the right supplies and education results in better diabetes control," says Wedell.

With the exception of Alabama, Idaho, North Dakota, and Ohio, all states now have similar laws on the books. Most, like Wyoming, mandate coverage for a broad range of diabetes equipment, supplies, and training. Three states—Georgia, Mississippi, and Missouri—require insurers to offer such coverage, but fall short of making it mandatory. Diabetic patients without private insurance may be eligible for services through either Medicaid or Medicare, which have expanded their diabetes coverage in recent years.

Given the alarming rise in the volume of adult diabetes in recent years, legislation aimed at controlling the disease would seem a sure-fire winner. And indeed the measures have won strong support in many places. Still, not everyone likes government meddling. And even those willing to make an exception in the case of diabetes aren't sure mandates work.

To help sort out these conflicting views, we sought opinions from doctors and HMO officials in several states. Their viewpoints tell us a lot about the pitfalls and pluses of mandating better health care.

Doctors and health plans declare a truce

In 1987, Wisconsin became the first state to require insurers to cover comprehensive diabetes services. By 1994, New York and Minnesota had passed similar bills, and Oregon had enacted legislation requiring insurers to cover self-management training only, not equipment and supplies. A trend was clearly developing, but not quickly enough for the American Diabetes Association. "Near the end of 1994, we made a strategic decision to promote mandate bills out in the states," says Michael Mawby, the ADA's vice president for government relations and advocacy.

The campaign worked. Since 1995, state after state has made coverage for diabetes services a top health care priority. And this year, in addition to new bills in Wyoming and Montana, Oregon amended its legislation to include coverage for supplies and equipment.

The proposal drew the support of both the Oregon Medical Association and some of the largest HMOs in the state. "Physicians and the insurance industry go to war over a lot of things, but with respect to the issue of diabetes there's been a kind of friendly truce," says James Kronenberg, the OMA's associate executive director.

Doctors want help in treating an often frustrating disease. Health plans want to control costs. Both sides win, Kronenberg says, when anyone makes it easier for doctors to help patients help themselves.

Allen Johnson, a pediatrician and medical director at Regence BlueCross BlueShield of Oregon, agrees. "Insurance companies are generally opposed to mandates, and with good reason," Johnson says. "But I think from the standpoint of simplifying the lives of physicians, certain mandates work. In the case of diabetes education and equipment, doctors now know they can make recommendations without worrying about whether a patient belongs to this or that plan."

Massachusetts—which in 2000 extended comprehensive coverage to all people with diabetes—is another state where organized medicine and insurers saw eye-to-eye. (Since 1994, the state had covered only insulin-dependent patients, and then only for blood glucose monitoring strips.) Testifying in support of the bill, the Massachusetts Medical Society said it would help the estimated 350,000 state residents with diabetes "live less limited and more productive lives." The measure would also prove cost-effective, said the society, "by limiting the anticipated inevitable costs of this disability—such as hospitalizations, dialysis, and organ transplants."

The health plan industry echoed these sentiments—then and now. "We supported the law and its backers because it gave our members the means to manage their diabetes [while it] helped to keep health insurance cost affordable," says internist Anne L. Meneghetti, the vice president of health care policy of BlueCross and BlueShield of Massachusetts.

Mixed reactions from doctors in the trenches

Practicing doctors are all too aware of the difficulty of treating and controlling diabetes, but they have mixed views about the state mandates.

Some are philosophically against government intrusion in medicine, whatever form it takes and whatever the purported benefit. "In America, we have too many of these stinking mandates," says Plainville, CT, internist Howard A. Grayson Jr. "They interfere with the practice of medicine and certainly drive up its cost." Internist Miles Hassell of Portland, OR, agrees, adding that "diabetes education outside of what the doctor should be doing anyway" is of "dubious clinical value."

Other doctors think laws mandating benefits are beside the point. What really counts in managing diabetes, they say, is patient cooperation and self-discipline. "We need a new miracle drug—'tincture of will power,'" says just-retired FP Ted J. Stuart Jr. of Glendale, AZ.

But not every doctor considers mandated coverage of diabetes services wrongheaded or an unwelcome intrusion. Though he complains about the "strict prescribing regulations" his state imposes, internist Robert P. Hill of Troy, TN, says the legislation makes a difference. "Provision of and payment for diabetic testing supplies help my patients achieve better control," says Hill.

Jeffrey M. Kagan, an internist in Newington, CT, underscores the point: "Having the Glucometer and supplies covered by Medicaid, Medicare, and HMOs eliminates one of the barriers to patients' assuming more responsibility for their care, and that usually results in better control of the disease."

Better patient compliance is a theme struck by many doctors we spoke to. Few, however, think the mandates make a difference in how they manage their diabetic patients. FP Robert W. Patterson of Sanford, NC, where the coverage bill is now four years old, is typical: "I was recommending the same treatment and self-management options before, but now I think patients are more apt to comply."

Still, some doctors say there's one area—diabetes re-education—where mandated coverage may have an impact on physician behavior. "Often, people who have had the disease for a few years need to go back to the dietitian, back to the diabetes educator, and learn more," says Wyoming's Eric Wedell. "Doctors are more likely to recommend re-education because under mandated coverage they won't hear a patient say, 'It's too expensive—I can't do it.'"

The next step: Better quality of care

On balance, mandated coverage of diabetes services appears effective in changing both patient behavior and—to an important but more limited extent—physician behavior. And each in its way contributes to better control of the disease's debilitating and costly symptoms.

But while the state mandates may help in this effort, they leave other areas largely unaddressed. "The state bills we helped pass don't say anything about quality of care," notes the ADA's Mike Mawby. For that crucial issue, he points to a number of state efforts to develop treatment guidelines, and to a major federal push under the auspices of the Diabetes Quality Improvement Project.

DQIP, as it's known, was sponsored initially by HCFA (now the Centers for Medicare & Medicaid Services), the ADA, the Portland, OR-based Foundation for Accountability, and the National Committee for Quality Assurance. Later sponsors and participants include the American Academy of Family Physicians, the American College of Physicians-American Society of Internal Medicine, Aetna US Healthcare, and the BlueCross BlueShield Association.

"DQIP," says Mawby, "is designed to raise the level of care." To do that, project leaders have developed two sets of measures—one relating to accountability, the other to quality improvement. An example of an accountability measure is the percentage of people in a given population who've had their hemoglobin A1c tested. The actual distribution of values for the test is an example of a quality improvement measure. To help plans and providers collect and report such measures, a DQIP users' guide and other tools are available.

As in the case of mandated benefits, the guideline approach, whether state or federally sponsored, isn't likely to please everyone. "Some physicians dislike guidelines and cookbook medicine, regardless of where it comes from," says the Oregon Medical Association's James Kronenberg.

Still, with diabetes on the rise and the cost pressures in health care as great as they've ever been, doctors may just have to hold their noses and swallow.

 

Wayne Guglielmo. Does mandated diabetes coverage boost compliance?. Medical Economics 2001;22:61.