Issues

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Issues Strategies for State Mandated Insurance
Coverage for Diabetes Self-Management Education
Navigating Existing Laws and Regulations to
Improve Health Care and Reduce Costs of Care for
Persons with Diabetes in Arizona

• Presentation by Dr. Jane Bolin, RN, JD, PhD
• Texas AM HSC School of Rural Public Health
• jbolin_at_srph.tamhsc.edu

January 18, 2008
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Objectives

• In this continuing education seminar we will
• Examine Arizonas AHCCCS goals, mission and
  vision and discuss how diabetes self-management
  education (DSME) falls squarely within AZs
  overall strategic quality vision, mission and
  vision.
• Discuss Arizonas regulations pertaining to
  commercial and employer sponsored health
  insurance and mandated quality standards
  pertaining to DSME.
• Examine what other states have required of MCOs
  and independent health plans in terms of
  mandating DSME classes for persons with diabetes.
• Investigate new federal and state initiatives
  relating to DSME classestie into federal and
  state regulatory powers.
• Formulate possible strategic policies and
  possible legislation to address identified needs
  for DSME benefits.

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Importance of Diabetes Self-Management Education
(DSME)

• Diabetes self-management education (DSME) is the
  foundation for the effective, long-term
  successful management of diabetes. (CDC, 2005)
• DSME has been shown to decrease health care use
  among Medicaid, Medicare and commercially insured
  recipients, particularly hospital admissions and
  ER visits. (Klonoff et al, 2000, Zhang, et al,
  2004 Balamurgan et al, 2006).

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The Legislative Policy Problem

• Many regard the mandatory provision of diabetes
  services, supplies, education and treatment as
  costly for health plans resulting in increased
  premium costs for all insured's, not just persons
  with diabetes. This drives purchasers away from
  coverage
• Most states (47) now mandate diabetes services,
  supplies and treatment for health plans subject
  to state regulation.
• However, several states, including Arizona, do
  not mandate diabetes education and behavioral
  health services directed towards diabetes
  prevention.

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What are the legal and regulatory issues facing
states?
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How is Health Insurance Regulated in the U.S.?

• The Basics Understanding why state legislators
  and state agencies are not able to simply mandate
  diabetes self management education coverage and
  other best practices for every citizen in the
  State of Arizona.

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A short primer of state federal regulation of
health insurance
AHCCCS Medicaid
Commercial Employer and Self-Purchased
Employer (self-funded) ERISA
Medicare
Managed
Non-Managed
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A short primer of state federal regulation of
health insurance
AHCCCS Medicaid
Commercial Employer and Self-Purchased
Employer (self-funded)
Medicare
Managed
Non-Managed
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Arizonas Medicaid System, a/k/a/ (AHCCCS)

• As the name implies, the Arizona Health Care
  Cost Containment System was established on the
  principle that quality of care and cost
  containment are not mutually exclusive outcomes.
• AHCCCS integrates the principles of managed care
  throughout acute care and long term care
  programs. Contracts with health plans require
  that a managed care organization (MCO) is capable
  of delivering all needed services in return for a
  prepaid monthly capitation. Admittedly, it was
  only after some initial ups and downs, that the
  Arizona Medicaid managed care program has become
  a model for other states. See
  http//www.nasmd.org/news/docs/Smiths_Committee_on
  20Aging_9-13-06.doc (2006 document)

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Arizonas Health Care Cost Containment System
(AHCCCS)

• According to Dr. Anthony Rogers, Director of
  AHCCCS, AHCCCS The Arizona Medicaid program
  was organized to avoid the financial and
  operational problems plaguing other state
  Medicaid programs. AHCCCS was built around the
  principles of managed care to control costs,
  assure quality of care, and provide access to
  primary care. (2006)

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Arizonas Medicaid Program AHCCCS Quality
Mission

• AHCCCS Quality Assessment and Performance
  Improvement Strategy is founded on AHCCCS
  mission of reaching across Arizona to provide
  comprehensive, quality health care for those in
  need.
• Inherent in carrying out the mission is the
  AHCCCS Administrations commitment to drive
  quality through the development of the Quality
  Strategy. The Agency then establishes its goals,
  objectives and timetables for health care
  improvements.

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• AHCCS 5-year Emphasis
• Continuous improvement in quality of care
• Integrated service networks and community
  resources
• Effective cost management, and
• Focus on member/provider assistance and
  service support by
• Maximizing information resources
• Increasing emphasis on disease management
• Increasing preventive care to reduce risk, and
• Enhancing e-health capabilities. (2004 Report)

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AHCCCS 5-Year Strategic Goals

• AHCCCS has adopted the following tenets as part
  of its five-year goals
• Enhance current performance measures and
  performance improvement projects and best
  practices activities by creating a comprehensive
  quality of care assessment and improvement plan
  across all AHCCCS Medicaid programs that will
  serve as a roadmap for driving member-centered
  improved outcomes. Objectives include
• Continuing use of nationally recognized
  protocols, standards of care, and benchmarks, and
  
• Establishing a system of rewards for physicians,
  in collaboration with its Contractors, based on
  clinical best practices and outcomes.

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AHCCCS 5-Year Strategic Goals

• Build upon prevention efforts and health
  maintenance to improve AHCCCS members health
  status through targeted medical management in the
  following areas
• o Emphasizing disease management
• o Improving functionality in activities of daily
  living
• o Planning patient care for the special needs
  population
• o Increasing emphasis on preventative care, and
• o Identifying and sharing best practices.

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Next steps for AHCCCS?

• How can DSME be incorporated into AHCCCS overall
  quality objectives?
• What evidence can be supplied from other states
  on the effectiveness of DSME in Medicaid
  populations?
• See Balamurugan et al, (2006), Diabetes
  self-management education program for Medicaid
  Recipients A continuous quality inprovement
  process, The Diabetes Educator, Vol 32 893-900.

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A short primer of state federal regulation of
health insurance
AHCCCS Medicaid
Commercial Employer and Self-Purchased
Employer (self-funded)
Medicare
Managed
Non-Managed
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Commercial and Employer Sponsored Plans

• Can be regulated by states.
• However, states wary of increasing insurance
  mandates because some mandates drive up costs for
  employer insured plansthereby causing smaller
  employers to drop insurance coverageleaving more
  uninsured.
• Willing to tie in quality and mainstream
  benefits. Must be convinced that mandated
  benefits wont drive up costs.
• States generally avoid unknowns.

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States that have mandated DSME by commercial plans

• See http//www.ncsl.org/programs/health/diabetes.
  htm
• According to the NCSL 46 states have some type of
  law mandating insurance coverage for treatment of
  diabetes. (See handout)
• However, only 20 states mandate coverage for
  DSME. Arizona is not among the states that
  require some form of DSME.
• State-by-state variations exist in the nature of
  DSME that must be provided as well as the amount
  or limits a health plan can impose.

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A short primer of state federal regulation of
health insurance (cont)
AHCCCS Medicaid
Commercial
Employer (self-funded)
Medicare
Managed
Non-Managed
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Employer-Funded Plans

• Employer
• (self-funded)
• Usually large, multi-state employers

• ERISA (Employee Retirement Income Security Act)
  is a federal law that governs all employer
  self-funded plans.
• States are barred from regulating self-funded
  plans
• Courts have tended to be very restrictive about
  what states can mandate (require) for Employer
  self-funded plans.

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• Self Funded Plans ERISA (cont)

• ERISA complicates the analysis of State mandated
  benefits laws because federal law preempts state
  regulation
• ERISA originally focused on employee pension
  benefitsCongress did not give much consideration
  to self-funded health insurance plans.
• Only recently has ERISA been amended to include
  requirements for group health plans that are
  similar to state mandated benefit laws.
• ERISA self-insured plans tend to be offered by
  larger corporations practicing in multiple
  states.

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U.S. Supreme Court ActivityLimiting ERISAS
Preemption

• In Rush Prudential HMO v. Moran et al, the U.S.
  Supreme Court (6 3 decision) upheld an Illinois
  law requiring all HMOs (including self-funded
  HMO plans) to provide for external review by an
  independent physician in all cases where the HMO
  has determined that a particular treatment or
  service is not medically necessary. In the event
  the reviewing physician determines the covered
  service to be medically necessary, the HMO shall
  provide the covered service.
• Significant because the Sup. Ct. ruled that
  states could regulate this as an area of medical
  care.

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A short primer of state federal regulation of
health insurance
AHCCCS Medicaid
Commercial Employer and Self-Purchased
Employer (self-funded)
Medicare
Managed
Non-Managed
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Medicare Plans
States have authority to regulate private and
commercial health insurance that offer Medi-gap
coverage, but not to set rates or mandate
benefits of basic Medicare coverage. This is an
area that is generally left up to DHHS at the
federal level.
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STRATEGIES FOR ADDRESSING THE NEED IN LIGHT OF
THE BARRIERS AND OBSTACLES

• Begin with AHCCCS Excellent mission and goals.
  Work with their legislative representative to
  craft legislation that would address including
  DSME in Medicaid plans.
• Examine other states approaches to mandating
  DSME.
• Present case studies and research to support need
  for DSME.

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According to the Council for Affordable Health
Insurance (Some form of) Diabetes
Self-Management (DSM) Benefits are now mandated
in 27 states.

• DSM mandates typically provide for evaluation,
  supplies, education and treatment. Yet,
  education services vary considerably among
  states.
• Arizona is listed to be among those who mandate
  DSMyet, like several other states, Arizona
  mandates only diabetes evaluation, treatment and
  supplies.
• Diabetes self-management education is NOT
  included among the mandates.
• (The NCSL lists only 20 states)

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What are the policy arguments in favor of
DSM-Education benefits?

• From http//www.teachdiabetes.com/need-for-educa
  tion.php
• Diabetes Studies Illustrate need for Education
• The State of Maryland recently conducted a study
  on the costs of providing comprehensive diabetes
  care, including education and supplies, for a
  group of Medicaid recipients who have
  diabetes.Results Enrollees had a 50 decreased
  risk of hospitalization, and a 50 decreased risk
  of an emergency room visit. There was an average
  savings of 4,598 per patient per year.

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What are the policy arguments in favor of
DSM-Education benefits?

• The State of Maine and the Centers for Disease
  Control and Prevention sponsored a diabetes
  self-management education program in 30 hospitals
  and health centers, following 1,488 patients over
  three years.Results Participants had a 32
  reduction in hospital admissions, with a saving
  of 293 per participant, or 3 saved for every 1
  spent on diabetes self-management education.
• http//www.teachdiabetes.com/need-for-education.ph
  p

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What are the policy arguments in favor of
DSM-Education benefits?

• In Los Angeles, as reported in the New England
  Journal of Medicine, 6,000 people participated in
  an integrated system of diabetes self-management
  education and care.Results Participants had a
  73 reduction in hospitalization and a 78
  reduction in average length of stay, for an
  estimated savings of 2,319 per patient per year.
• http//www.teachdiabetes.com/need-for-education.ph
  p

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Wisconsin Studyhttp//www.lbo.state.oh.us/fiscal/
fiscalnotes/124ga/HB0100IN.HTM

• Wisconsin conducted a study to assess the costs
  of mandated diabetes education, equipment, and
  supplies.
• After Wisconsin passed its diabetes mandate in
  1987, its Insurance Commission studied the costs
  of a standard benefits package on five insurers.
  Of the total medical benefits paid in 1987,
  762,666,109, the dollar amount spent on required
  diabetes related coverage was 624,460 or less
  than 1. In 1988 the percent of the total was
  1.1 (835,240 out of a total 752,563,830). The
  Commission concluded that directing the five
  insurers to offer diabetes supplies and education
  coverage did not increase claims filed,
  disbursements, costs, or premiums, when compared
  to non-mandated benefits.
• In 1990 Wisconsin stopped surveying for the costs
  of diabetes, home health care, skilled nursing
  care, and kidney disease treatment mandates,
  because they were small dollar figures. In
  addition, the cost of these four mandates added
  together were less than 1 of the total medical
  benefits.

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What are the policy arguments in favor of
DSM-Education benefits?

• The Diabetes Control and Complications Trial
  (DCCT), a very large clinical trial carried out
  by the National Institutes of Health, compared
  clinical outcomes of people receiving standard
  diabetes care with those receiving intensive
  diabetes self-management education. Necessary
  supplies were provided for all study
  participants.Results The DCCT showed that when
  people with diabetes are given the knowledge and
  the supplies they need to control their blood
  sugar, diabetes complications were reduced by an
  average of 60."The greatest problem we have in
  our country is that we have a health-illiterate
  society. We do not have a health care system. We
  have a very expensive 'sick care'
  system."              - Former Surgeon General
  Dr. Joycelyn Elders
• http//www.teachdiabetes.com/need-for-education.ph
  p

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• Next Steps How to get there from here?
• Brainstorming
• How does Arizona Diabetes Coalition take this
  information to the next step?
• Who are ADCs logical partners
• What kind of legislation/mandate should be
  requested?
• Example of Advocacy Group approaches
• http//www.dagc.org/advocacy/dcrafaqs.asp

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Sample legislation

• Kansas Chapter 40-2,163
• Chapter 40.--INSURANCE Article 2.--GENERAL
  PROVISIONS       40-2,163.   Coverage for certain
  expenses relating to care and treatment of
  diabetes educational expenses exceptions. (a)
  This section shall be known and may be cited as
  the "diabetes coverage act."
•       (b)   Any individual or group health
  insurance policy, medical service plan, contract,
  hospital service corporation contract, hospital
  and medical service corporation contract,
  fraternal benefit society or health maintenance
  organization which provides coverage for accident
  and health services and which is delivered,
  issued for delivery, amended or renewed on or
  after January 1, 1999, also, shall provide
  coverage for equipment, and supplies, limited to
  hypodermic needles and supplies used exclusively
  with diabetes management and outpatient
  self-management training and education, including
  medical nutrition therapy, for the treatment of
  insulin dependent diabetes, insulin-using
  diabetes, gestational diabetes and noninsulin
  using diabetes if prescribed by a health care
  professional legally authorized to prescribe such
  services and supplies under the law. Such
  coverage shall include coverage for insulin only
  if such coverage also includes coverage of
  prescription drugs.
•       (c)   Diabetes outpatient self-management
  training and education shall be provided by a
  certified, registered or licensed health care
  professional with expertise in diabetes. The
  coverage for outpatient self-management training
  and education shall be required pursuant to this
  section only if ordered by a health care
  professional legally authorized to prescribe such
  services and the diabetic (1) is treated at a
  program approved by the American diabetes
  association (2) is treated by a person certified
  by the national certification board for diabetes
  educators or (3) is, as to nutritional
  education, treated by a licensed dietitian
  pursuant to a treatment plan authorized by such
  healthcare professional.

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Kentucky

• 304.17A-148 Coverage for diabetes.
• (1) All health benefit plans issued or renewed on
  or after July 15, 1998, shall provide coverage
  for equipment, supplies, outpatient
  self-management training and education, including
  medical nutrition therapy, and all medications
  necessary for the treatment of insulin-dependent
  diabetes, insulin-using diabetes, gestational
  diabetes, and noninsulin-using diabetes if
  prescribed by a health care provider legally
  authorized to prescribe the items.
• (2) Diabetes outpatient self-management training
  and education shall be provided by a certified,
  registered, or licensed health care professional
  with expertise in diabetes, as deemed necessary
  by a health care provider.

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Montana

• Section 1.  Coverage for outpatient
  self-management training and education for
  treatment of diabetes -- limited benefit for
  medically necessary equipment and supplies. (1)
  Each group disability policy, certificate of
  insurance, and membership contract that is
  delivered, issued for delivery, renewed,
  extended, or modified in this state must provide
  coverage for outpatient self-management training
  and education for the treatment of diabetes. Any
  education must be provided by a licensed health
  care professional with expertise in diabetes.
•      (2) (a) Coverage must include a 250 benefit
  for a person each year for medically necessary
  and prescribed outpatient self-management
  training and education for the treatment of
  diabetes.
•      (b) Nothing in subsection (2)(a) prohibits
  an insurer from providing a greater benefit.

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Other helpful websites and articles

• AHCCS Performance Measures for Diabetes Care,
  November 2004
• AHCCS Quality Assessment and Performance
  Improvement Strategy, October 2004.
• New Yorks Law http//www.diabetesmonitor.com/ny.h
  tm
• Connecticuts law http//www.cga.ct.gov/2004/rpt/2
  004-R-0148.htm
• Texas http//www.tdi.state.tx.us/rules/2003/0703-0
  59.html
• ADEA ppt http//www.atlantadiabetes.org/html/March
  07_Mem_Meeting.pdf
• Legislation summary http//journal.diabetes.org/d
  iabetesspectrum/99v12n4/pg222.htm
• Diabetes Spectrum Article http//spectrum.diabete
  sjournals.org/cgi/content/full/19/1/54
• Illinois law http//www.idfpr.com/doi/HealthInsur
  ance/Mandated_benefits.asp
• NCHL state-by-state summary http//www.ncsl.org/
  programs/health/diabetes.htm
• GAO Report GAO-05-210 Managing Diabetes Health
  Plan Coverage of Services and Supplies. Report
  to Congress. February 2005
• Studies on the benefits of disease management
  http//www.npcnow.org/resources/PDFs/P46.pdf

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Tips for Working Effectively with your
Legislators http//www.aia.org/SiteObjects/files/h
owtolobby.pdf (American Institute of Architects)
General Tips for Communicating with Congressional
Staff Try to talk to the right staff person.
Ask whether the staff member you reach handles
the issue you are concerned about. If the issue
is related to tax policy, make sure you are
working with the staffer who handles tax policy.
If you have a pre-existing relationship with
another staffer, involve that staffer in initial
meetings, but ask to be put in touch with the
person who handles the specific issue. Use the
right method of communication. Telephone and e-
mail contact work best. Telephone calls allow
interactive communication, and e- mails allow for
detailed communication records. Work with staff
to find out which method of communication they
prefer. Remember that regular mail is not an
alternative for Capitol Hill communication since
the anthrax attacks, it takes weeks to reach the
Congressional offices. Be informed about the
issues you are lobbying. Use your role, as a
respected professional with extensive experience,
to become a relied upon source for information.
Dont be turned off by Hill staffers they often
have the elected officials ear. Show them
respect, and they will take your issue to the
elected official. It is good to have a working
relationship with staff.
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Message How to Talk to Your Legislator 12
Tips 1. Feel good about what youre doing.
Constituents visiting legislators is
what representative democracy is all about. 2. Be
friendly and respectful, even if you dont
ordinarily support a legislators politics. 3.
When you meet a public official, create a
personal bond right from the start. 4. Once
greetings are completed, explain why youre
there. Get to the point quickly. 5. Ask your
legislator to do something specific. And when you
do, be clear and precise. 6. Legislators and
their staffs are very busy. Use the time
effectively. 7. Dont overstate your case. Stick
to reasonable arguments based on the facts. 8.
Dont be afraid to express an informed opinion
about an issue even if youre not an expert.
Also, dont be afraid to explain your technical
credentials if you are, in fact, an expert. 9.
Listen for an actual commitment of supportnot
something that may sound like one, but really
isnt. 10. If your legislator disagrees with your
viewpoint, dont get angry and never make a
threat. 11. Never offer an elected official
anything in return for their support and never
discuss campaign finances, PAC contributions, or
endorsements. 12. Get to know key legislative
staff members. They often have great influence
and can be extremely helpful as follow-up
contacts.
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QUESTIONS?

• Contact Info jbolin_at_srph.tamhsc.edu