Health Policy Researchers: System Fragmentation Hindering Progress on Diabetes Care

A team of healthcare policy researchers has taken an in-depth look at how the U.S. healthcare system cares for individuals living with type 2 diabetes, and has outlined a range of issues inhibiting the system from doing a better job of improving health status. In an article in the July issue of Health Affairs, Puneet Kaur Chehal, Elizabeth Selvin, Jennifer E. DeVoe, Carol M. Mangione, and Mohammed K. Ali provide a thorough analysis in their article, “Diabetes And The Fragmented State of US Health Care Policy,” Indeed, the authors write that, despite the fact that 37.3 million Americans are currently diagnosed with type 2 diabetes, and the fact that a very large and robust clinical literature exists to support clinicians caring for diabetic patients, a number of extremely daunting challenges built into the U.S. healthcare system continue to hinder progress in improving health status for diabetics.

Among the key issues the authors comment on are the following: fundamental fragmentation in the healthcare system; the heterogeneity of health insurance systems, and the regular displacement of individuals from coverage by one health insurer to another; and fragmented service delivery inside patient care organizations.

When it comes to fragmentation, the authors write that “Fragmentation is rooted in how health services evolved in the US. During and after the Civil War, health services were delivered by physicians on a fee-for-service basis at the point of care. At the turn of the twentieth century, third-party insurance payment mechanisms were established to expand access to health services for all Americans. Over time, US health care evolved into a quasi-public-private system that still largely uses fee-for-service arrangements between third-party payers and health care delivery systems. As a result, Americans have autonomy and responsibility over their own health, but there is very little focus on population health and equity.”

What’s more, the article’s authors write, “Payers or insurers for health services in the US segment the population by age, income, disability, immigration status, and employment. Since household circumstances or, if applicable, employer-chosen plans dictate the options, Americans are distributed across a mix of public, private, and both types of health insurance; others lack health insurance completely.” And, “Even within payer types, there is heterogeneity. For example, commercially insured people can have managed care, high-deductible, or preferred provider benefit plans. Lack of transparency and variation in plan benefits can hinder the access that people with diabetes have to services and treatments. In addition, there is little, if any, coordination and continuity of benefits as people move between payer types.”

Given that, they note that, “At the individual level, chronic conditions such as diabetes require person-centered prevention, care, and vigilance, and they are particularly sensitive to disruptions in insurance coverage. Transitions that occur as a result of changes in employment status or age, as well as movement between individually purchased plans, are associated with coverage changes, and there is potential for discontinuity in the networks, services, and medications that people with diabetes can benefit from,” they write. “In addition, annual formulary changes imposed by payers subject people with diabetes to changes in coverage or copays to maintain their medication regimens.”

And, the article’s authors note, the very architecture of care delivery in the U.S. healthcare system continues to hinder sustained progress in improving the care management and health status of many diabetics. They write that “Similarly, the movement of people between health systems undermines incentives for long-term, high-value care. Health systems and clinicians who deliver preventive care and treatment for people with chronic conditions might consider it their responsibility to achieve good health outcomes for those they serve. However, many payers still reimburse clinicians and delivery systems using fee-for-service payment. Fee-for-service incentivizes volume and high-cost service delivery, so there is low incentive to optimize high-value services (such as nutritional counseling) to keep people with diabetes out of the hospital where, instead, they can receive high-cost, highly reimbursed services such as dialysis, amputations, and surgical procedures. The purchasers of coverage—employers or individuals themselves—should be incentivized by the good health of beneficiaries to minimize expenditures and lost productivity associated with chronic conditions such as diabetes. That said, employers and individuals go where premiums are affordable, within the bounds of what insurers or insurance exchanges offer. Asymmetry of information and lack of price transparency hinders employers and individuals from recognizing that they are purchasing and receiving poor-quality, low-value care, respectively.”

At the highest level, they write that “Fragmentation in health policies, payers and reimbursement design, and delivery of diabetes prevention and treatment services is emblematic of the decentralized US health care landscape. Reducing persistent individual- and population-level diabetes burdens and inequities will require a more coordinated approach that affords greater concentration on high-value services, alignment of incentives, and continuity of information and services. To be sure, even with the epitome of health-sector reforms, since diabetes burdens are multifactorial, the US still might not be able to get ahead of these devastating diabetes trends; complementary non-medical interventions and policies also are needed to truly optimize metabolic health and equity for all Americans.”