Managed Care Innovator—Certified Diabetes Educator: Tommy Johnson

The diabetes diagnosis. For managed care, it means facing average expenditures a staggering 2.3 times greater than for someone without the diagnosis. And, according to the Centers for Disease Control and Prevention, the rate of diagnosed diabetes has increased 4-fold from 1980 through 2014 (from 5.5 million to 22 million). Yet the fortunate irony of diabetes is that despite its staggering health impacts and subsequent costs, it’s a chronic disease in which lifestyle modifications can make a significant difference.

Certified Diabetes Educators, or CDEs, certified through the National Certification Board for Diabetes Educators (NCBDE), have the potential to be managed care’s white knights in the war against diabetes costs. A CDE is uniquely qualified to educate people with diabetes on just the sort of lifestyle modifications and self-management tools that can help minimize complications. Yet today, utilization and reimbursement policies for diabetes educators varies greatly from state to state.

Two bills, H.R. 1726 and S.1345, introduced last year and both titled “Access to Quality Diabetes Education Act of 2015” aim to improve access to diabetes self-management training. If passed, it would authorize CDEs to provide diabetes self-management training services, including as part of telehealth services, under Part B of the Medicare program. 

With both bills pending, First Report Managed Care (FRMC) sat down with Tommy Johnson, newly elected Chair of the NCBDE Board of Directors, to talk about CDEs, their effectiveness, and the status of the 2 diabetes education bills.

FRMC: What does managed care need to know about what a CDE does? 

Johnson: A CDE is a health professional who possesses comprehensive knowledge of and experience in prediabetes, diabetes, diabetes prevention, and all types of diabetes management. A CDE educates and supports people affected by diabetes so that they understand how to manage the condition and gain the skills and confidence necessary to do so. CDEs work with other health professionals as a team to achieve individual and population management health improvements. When they voluntarily become CDEs, diabetes educators, who can come from many different health care backgrounds, take an important step in demonstrating their knowledge to other health professionals, their team, and people with prediabetes and diabetes.

(NCBDE Note: As of January 2016, 19,262 health professionals held the CDE credential. The general breakdown of CDEs by discipline/profession is as follows: 51% nurses, 40% dietitians, 7% pharmacists, with the balance being made up of all the other disciplines.)

FRMC: Are there measurable statistics on outcomes for people with diabetes who work with a CDE as opposed to those who don’t? 

Johnson: There haven’t been any specific studies done at this time—though there are a number of studies showing improved outcomes when patient education is provided, but this is something that needs to be done and we hope can be done in the future. There have been some studies with nurses—including one with perioperative nurses in the hospital setting—showing that nurses who have received related certifications can have better patient outcomes, which can result in decreased length of stay and decreased hospitalization costs.

FRMC: Decreased hospitalization costs are good considering the costs associated with diabetes are just staggering in terms of medications, emergency room visits, and related complications. 

Johnson: In addition to that, just managing a chronic condition can have a cost in terms of relationship stress and other aspects that have an impact on health. As a chronic condition, there’s a high incidence of depression, and diabetes can impact the person at home, at work, and at school. It affects many different areas of life. For instance, when I was providing diabetes education in a clinic setting, there were individuals experiencing depression who just were really not in a place where they could take care of any parts of their lives. We had to help them address their depression first by working with their providers to refer them to an appropriate health professional to address the depression before we could do anything else. 

FRMC: They didn’t have the motivation to manage diabetes properly.

Johnson: Right. Or, they weren’t able to manage their diabetes at any level. We had to get beyond that barrier first before we could help them think about blood sugar control. Say they had a starting A1C of 12%, but they were at a stage where they really didn’t care. When they started to care about themselves, then we could move forward in supporting their management efforts. So this is really a team approach and the CDE has the knowledge to look for things and identify the whole person and refer them to different sources so that their overall health can be improved.

FRMC: Consulting a CDE sounds like a great asset, but is it covered by insurance?

Johnson: We don’t have any way to control whether an insurance company does or doesn’t cover a CDE under their plans. Coverage is always complicated. A lot of times it’s a state-by-state issue, so in some states Medicaid pays for diabetes education; in some states they don’t. In some states, commercial insurance companies pay for it, other states, they don’t—or they pay only for certain things. We think that coverage is an important thing to occur. Medicare does pay for diabetes education, but they have certain criteria and stipulations. For Medicare reimbursement, you have to be a recognized program through the ADA [American Diabetes Association] or the AADE [American Association of Diabetes Educators] first, and then you have to follow certain curriculum and educators can only see a person for up to 10 hours and provide that amount to be covered under Medicare. So, there are a lot of barriers as far as insurance reimbursement and it’s so state-specific that we tend to look at it from a Medicare standpoint. But as far as commercial insurance and Medicaid, it’s very individualized. 

FRMC: Is there anything you would want to say to insurance companies that don’t cover education?

Johnson: Really, covering diabetes education provided by a CDE is one way to identify that the education is provided by someone who has made a commitment to obtaining and maintaining a level of knowledge about diabetes. With the education, the cost of providing coverage to people with diabetes should decrease over time and hopefully reduce the long-term cost of diabetes. We can identify and address some of the health issues that may never get addressed when an educator is able to spend time with the individual—like depression, or anxiety, or looking at their blood pressure and their cholesterol in addition to their blood sugar. A lot of people who do not have insurance coverage for diabetes never receive diabetes education, period, let alone from a CDE. Investing in education, we think, would decrease the overall health care costs in the long run for an insurance company. 

FRMC: How can the use of a CDE be an innovation in achieving value of care?

Johnson: Diabetes education has been around and available for many years, along with the concept of certification in health care. But diabetes education has also been an underutilized benefit of Medicare. So even if you looked at statistics, the utilization of diabetes education in a Medicare population is really low. Individuals with diabetes should be encouraged to obtain this education and support not just when they’re initially diagnosed, but periodically because things change. Their health changes. Medications change. Technology changes. Both the individuals with diabetes and the insurance companies could see positive outcomes. 

FRMC: That brings up a good point: it’s not just initial consultation, but an ongoing dialogue with the person with diabetes. 

Johnson: I’ll give you an example of how things can change. I primarily worked in a free clinic environment, and we had a lot of patients who had lost their jobs for the first time since they had been diagnosed with diabetes. When they lost their jobs, they lost their insurance. I know one gentleman who had owned his own business, but when he lost his business, he lost his insurance. He was a very well-educated gentleman as far as his diabetes management, but his situation had changed, and so we had to look at how he could manage his diabetes now, instead of what had worked for him a year ago.

FRMC: It almost seems like when it comes to diabetes, the actual diagnosis is a day late and a dollar short. Do you see trying to move toward prediabetes education to avoid as many cases of diabetes as you can?

Johnson: Yes, and I think that prediabetes education is already occurring in certain areas of the country. But I think that more needs to be done to prevent and minimize the number of people that go from having prediabetes to diabetes. So I think there’s a lot a CDE can do with helping those folks understand the importance of lifestyle modification, and, in some cases, medications, but primarily the lifestyle modifications. Just helping them understand what is a carbohydrate and why does it matter. Because those are some of the things that, if addressed earlier, may prevent or drastically move the onset of diabetes many years down the road, which again would minimize that health care cost, and also the burden placed on that person.  

FRMC: It seems it would potentially be a great bang for your buck reimbursing aspects of prediabetes testing and education in an effort to avoid the ultimate costly diagnosis. 

Johnson: I can just tell you from a personal standpoint, when I would meet with people individually for the first time, the majority of the time they weren’t able to understand when I’d say, “What would you like to learn today?” They wanted to learn what they could eat, and how much they could eat. So, just having that basic understanding of the lifestyle modification, not only the meal planning, but also physical activity and different things and what works for them, and individualizing it. Those steps right there had a huge impact on not only their clinical numbers but also on their personal wellbeing. 

FRMC: How would the 2 bills (both titled “Access to Quality Diabetes Education Act of 2015”) affect private health insurance in reimbursing for CDEs?

Johnson: NCBDE didn’t draft or submit either of these 2 bills, but we have reviewed and do support them. It’s hoped that if either of these bills becomes law it would result in expansion of providers of diabetes self-management training, also known as diabetes self-management education (DSME), under Medicare, and there are significantly more CDEs than Medicare-approved DSME programs available at this time. There’s also hope that private health insurance companies that have not done so in the past would match what Medicare is doing by covering diabetes education provided directly by CDEs. Also the development of recommendations for how to educate physicians, other health care providers, and the public about the benefits of DSME would encourage increased access. Overall, if either bill can significantly increase access for people with diabetes to diabetes education, it will subsequently positively impact the health of those individuals, their families, and even eventually, the US economy.