Fragmented care stalls progress in diabetes reduction

Progress in treating and preventing Type 2 diabetes in the U.S. has stalled over the past decade, and regaining momentum will require a coordinated effort among lawmakers, clinicians and public and commercial payers, according to a recent article in Health Affairs.

Currently about 37 million Americans have diabetes, a 40% increase from 10 years ago, the article notes. Moreover, inequities in access to care and preventive services mean that Black and Hispanic adults are 1.5 to 2 times more likely to develop the disease, and significantly more likely to die from it, than are non-Hispanic white adults.

The authors say much of the backsliding in diabetes prevention and treatment is due to fragmentation in the nation’s health care system, which they define as “siloed or heterogeneous health services that occur because of the lack of unified goals, policies, incentives, and information across stakeholders.” This results in “uncoordinated and highly variable care that deviates from evidence-based recommendations, thereby undermining population health goals and equity.”

Fragmentation has been especially harmful to diabetes treatment and prevention when it comes to health policy and governance, payers and reimbursement design, and service delivery. In health policy and governance, they cite the example of division of authority between Medicare, which is a federal program, and Medicaid, where states largely control the design and implementation of the program.

“Fragmentation…at different levels diminishes accountability and coordination, both of which are necessary to prevent and manage diabetes,” they write.

An example of harmful fragmentation in the category of payers and reimbursement design, they say, is Americans’ frequent movement among health systems. This undermines those institutions’ incentives for preventive care and treatment of chronic conditions such as diabetes. The problem is exacerbated by fee-for-service reimbursements, which reward volume and high-cost services and offer little incentive for services such as nutritional counseling that patients with diabetes need.

In service delivery, the authors say, people with diabetes are harmed by the siloing of services, often finding it difficult to navigate between those provided by primary care physicians and specialists, as well as different specialties. In addition, when patients transition between health care systems, it creates a high risk of discontinuity for their personal health information due to widespread lack of information sharing. The result, they say, is “discontinuity of care, weate, and disjointed surveillance across systems and states.”

The authors offer three broad remedies for addressing the problems fragmentation creates for people with diabetes, including:

• Legislating coverage for evidence-based services: Mandating that payers provide full coverage of specific preventive and treatment services grounded in clinical trial data, they say, “expands the reach of evidence-based preventive and therapeutic options to bend the population curve of diabetes burdens.”
• Aligning incentives with high-value services: Central to this is moving from fee-for-service to value-based alternative payment models such as capitation. Doing so would increase providers’ incentives to offer high-value services to patients with or at risk for diabetes while reducing providers’ doctors’ administrative burdens and reducing costs for health systems.

“Compared with the US, experiences in countries with greater payer and delivery alignment are characterized by more stable coverage and access to services and medications,” they note.

Promoting continuity and quality through information management: “Health information sharing is a critical tool for measuring, monitoring, and rewarding improvements in outcomes,” the authors say. “However, to achieve this in the pluralistic market-based US health care landscape, over-arching government policy and regulation, along with funding support, are likely to be the only credible paths toward establishing sustainable business models that incorporate health information sharing.”

The article, “Diabetes And The Fragmented State Of US Health Care And Policy” appears in the July, 2022 issue of Health Affairs.