Diabetes Coalition Stands Up To HMO’s

Now that HMOs have become the most popular choice of health plan for employers, some employees-especially those with diabetes-have found themselves disappointed with the care they receive. Many HMOs do not provide lancets, blood test strips, alcohol swabs or syringes. Many do not cover the cost of specialists such as podiatrists or ophthalmologists.

A newly formed group called the California Diabetes Coalition has taken on the task of advocating to improve care for people with diabetes. The coalition is working to ensure that HMOs make their decisions based on the interests of the diabetic patient.

In 1993, California was one of 13 states to receive funding to create a diabetes program specifically for the state. Leaders from the California diabetes community-doctors, nurses, and diabetes educators-were invited to a conference to help develop the program. Volunteers from that three-day conference decided to create the California Diabetes Coalition.

The coalition has set several goals. One was to come up with specific guidelines, listing the minimum services required by a person with diabetes. This first step has been done (see accompanying table). Now, the coalition hopes to acquaint the diabetes community with this list.

The guidelines are based on the DCCT test, which proved that the most effective method for a person with type I diabetes to stay healthy is through tight control of HbA1c levels. Joan Werblun, the coalition’s chairperson, is quick to point out that the guidelines are only baseline necessities for a person with diabetes. They do not represent an ideal, and cannot be called standards.

“We don’t want to create a set of guidelines cut in stone which prevents a doctor from individualizing his or her own program. We just want to communicate what a person with diabetes needs and deserves,” said Werblun.

Kriss Halpern is an attorney who works as the vice-chair of the coalition’s advocacy committee. He takes care of another part of the coalition’s mission, making sure that people with diabetes are aware of what their doctors should be providing. Halpern believes if patients lobby for what they deserve, they will convince HMOs to implement these guidelines. The coalition seeks to demonstrate to managed-care programs that better care will save money in the long-run.

“The HMOs try to save costs on the basic necessities, but they’re not looking long-term. If a person with diabetes has access to a certified diabetes educator, to an eye doctor and a foot doctor, then the hospital will avoid costly surgeries down the road,” said Halpern.

He believes a health care provider has a responsibility to do everything in its power to encourage a person with diabetes to control his or her blood glucose levels. This encouragement, Halpern said, includes the cost coverage of test strips, glucose meters, insulin pumps and access to a diabetes educator.

“It’s hard enough for a person with diabetes to maintain tight control of his or her HbA1c levels. It takes time and effort. An HMO has a duty to make it easier for a person to take care of himself, not create more obstacles. If a person has a greater chance of lowering his HbA1cs with an insulin pump, then the HMO should cover the cost of a pump,” said Halpern.

One way HMOs control costs is through “utilization review” companies. For a small monthly fee, the utilization review companies save HMOs money by controlling the number of “unnecessary” surgeries and limiting “excessive” days a patient may spend in the hospital. According to Werblun, many HMOs capitate the supplies for diabetic patients, covering the costs of lancets for type I patients but not for type 2 patients.

“It’s ridiculous to offer it to one type of patient and not the other. The results from the DCCT suggest that it’s just as important for type 2s to control their HbA1c levels as it is for type Is. The physician’s decisions are not being based in the best interests of the patient, but on short-term financial decisions,” said Werblun.

Gary Arsham, MD, of the DIABETES HEALTH advisory board and member of the coalition, says HMOs are not the coalition’s only target.

“We’re not focusing exclusively on managed-care. We’re enlisting the support from every kind of healthcare program,” said Arsham. “Our job is to demonstrate that better diabetes care will save money in the longterm.”

As Arsham said, the coalition seeks to improve the standards of healthcare on a broad scale, beginning with the diabetic patient. With the publication and dispersion of the coalition’s guidelines, each person with diabetes will receive the framework of a healthy diabetes maintenance program. The diabetic patient will know what to expect and demand, if necessary, from his or her health care provider.

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