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Effective management of Type 2 diabetes usually requires a multi-pronged approach that includes drug therapies and lifestyle changes. Patient adherence to a plan is the main challenge for primary care physicians.
About 19 million Americans have diabetes, and the American Diabetes Association (ADA) estimates the rate of increase for the disease at 7% to 8% annually.
“I don’t know any other chronic disease that’s growing at 8% each year. That’s why we’re sounding the alarm,” says John Anderson, MD, president of medicine and science for the ADA.
Effective management of Type 2 diabetes-which includes between 90% and 95% of all diabetes cases-usually involves a multi-pronged approach that includes drug therapies and lifestyle changes. The challenge for primary care physicians (PCPs) is getting patients to adhere to the plan. A 2010 study in The New England Journal of Medicine found that between 33% and 48% of patients with diabetes did not meet targets for blood pressure, glycemic control, or low-density lipoprotein levels, three of the main symptoms of the disease.
“We know that if we can get people to exercise more and change their eating habits to lose a certain percentage of weight, we markedly reduce the rate at which pre-diabetic patients turn into full diabetes,” says Anderson.
Patients with Type 2 diabetes do not produce enough insulin to convert blood sugars (glucose) into energy for the body, causing glucose levels build up in the body. If left untreated, high glucose levels can lead to complications such as blindness, loss of limbs, kidney failure, and neuropathy. The disease can also exacerbate the effects of conditions such as high blood pressure and high cholesterol levels. The ADA puts the annual cost of all forms of the disease at about $245 billion, including $176 billion in direct medical costs and $69 billion in reduced productivity.
In light of diabetes’ growing prevalence, it’s not surprising that a wide and ever-expanding range of drug therapies and monitoring technologies are available to help doctors and patients cope with the disease and limit its effects. Anderson cites as examples the development of a new Incretin class of medications and the U.S. Food and Drug Administration’s recent approval of a new class of sodium-glucose co-transporter 2 inhibitors.
In addition, the explosion of health-related apps has given physicians and patients new tools to help with diabetes management. (A summary of some of the latest apps that can help people with diabetes can be found at: http://forecast.diabetes.org/apps-jan2013).
In most cases, however, physicians prefer to try controlling the disease-or better yet, preventing it-by emphasizing lifestyle changes-which gets back to the challenge of adherence. For many years the standard approach was simply to tell patients what they needed to do and leave it to them to figure out how to do it. But research, as well as doctors’ own experiences, has demonstrated the limitations of this approach.
“What everyone has been finding is that patients often don’t do what you tell them to do,” says Richard Waltman, MD, a family and geriatric practitioner in Tacoma, Washington, and a Medical Economics editorial consultant. “So the key is to get them to tell themselves what to do. What I’ve learned to do is to give patients the data [of their condition], show them the benefits of treatment, and ask them what they want to do. That way it becomes their plan.
“If someone isn’t ready to change, nothing works,” Waltman adds. “When they are ready, everything works.”
Other techniques suggested by experts and by PCPs with experience in treating diabetic patients include:
Patients of Patricia Roy, DO, a family practitioner in Muskegon, Michigan, receive a report card that grades them on important diabetes metrics such as blood pressure, glycated hemoglobin (A1c), and low-density lipoprotein levels, as well as frequency and results of eye and foot exams.
“Our pay-for-performance scores, and therefore our income, increased significantly by giving our patients these report cards,” says Roy, who is also a Medical Economics editorial consultant. “I am continually amazed at how often they show them to their family, and how often they hang them on their refrigerator at home,” she adds.
The involvement and support of family and friends is a significant element in patient success when it comes to making diet and lifestyle changes. “We often talk about diabetes being a disease of the entire family,” notes Anderson. “What good does it do to discuss diet with the husband alone when he never shops or cooks? You have to consider the family dynamics, who’s in charge of what at home.”
“It’s really important to appreciate how much support and encouragement is needed to make the kinds of changes that most patients with Type 2 diabetes need to make,” says Molly Cooke, MD, FACP, president of the American College of Physicians and a practitioner in the general internal medicine division at the University of California-San Francisco. “So one of the things I do with my patients is encourage them to look for a buddy, or join a weight management program where there’s a social dimension to help them with that change in behavior.”
PCPs can also benefit from a team approach to providing diabetes care for patients, especially in light of the time pressure most of them face. “It would be nice to be able to spend 30 minutes with every patient, but we don’t have that luxury, Anderson points out. “So as a PCP you have to be very efficient. You’ve got to have a team approach to dealing with diabetic patients.”
Current staff members often can be helpful, especially in smaller or rural practices, says Edward Shahady, MD, medical director of the Diabetes Master Clinician Program in Fernandina Beach, Florida and former president of the ADA’s North Florida/South Georgia chapter. “A lot of family practices will have someone in the office who’s learned a lot about diabetes, and they can help with simple education tasks,” he notes.
Anderson recommends the use of a nurse educator and dietician to help with patients with diabetes. Practices unable to hire additional staff can often refer patients to community resources, such as local hospitals, for nutrition counseling, smoking cessation, and other resources related to diabetes management, he adds.
The value of this technique, doctors say, is that it enables patients to learn from and support each other in attaining their goals. Shahady began teaching residents how to conduct group visits a decade ago when he was a professor of family medicine at the Florida State University School of Medicine. “In a one-on-one visit, the doctor only has so much time and usually winds up doing most of the talking,” he says. “In the group visit the patients get to talk and help each other out.”
Cooke cites the example of a woman having difficulty attaining her goal of walking 30 minutes a day because of her responsibilities of housework and caring for her grandchildren. “It’s more helpful if someone else in the group says, ‘I had that problem too and I tried this.’ So they end up coaching each other.”
Those who hold group appointments say they are also useful for educating patients. Shahady, for example, says he will often ask patients to bring in items of canned and packaged foods so that group members can help each other learn how to read the labels for calories and sodium and fat content. Cooke began offering instruction in using glucose meters after a group visit where patients brought in their meters and she discovered that half of them had dead batteries. “The patients didn’t understand them well enough to know they don’t work if the battery is dead,” she says.
Group appointments can be structured in a variety of ways depending on the needs of the patients and preferences of the physician. Some begin with an instructional session, either by the physician or a specialist such as a dietician or pharmacist, whereas others will be open discussions and/or questions from patients about challenges they’re facing. In all cases, however, doctors recommend limiting attendance to no more than about 12. “Any more than that you’re going to have a lecture,” Shahady says.
Shahady adds that he bills for the group visits using standard evaluation and management (E/M) codes, but doing so requires careful documentation. (See “Coding and billing for group appointments.”) “The rules for E/M codes don’t say one on one, they say face to face,” he notes. “So if I’m talking to the group about A1c, even if a patient doesn’t get involved with the discussion, I can enter something on her chart that hemoglobin A1c was discussed.”
The coming rollout of the Affordable Care Act (ACA), in conjunction with the emergence of payment models such as accountable care organizations, have given some doctors ground for cautious optimism regarding improvements to diabetes care. Shahady thinks the expansion of Medicaid eligibility and limitations on insurance companies excluding people for pre-existing conditions under the ACA should benefit many of those who have the disease. “I’ve had many, many patients tell me they can’t get insurance because they are diabetic,” he says.
Cooke thinks physicians will benefit from payment models that allow them to be compensated for coordinating the care among specialists, such as nephrologists and cardiologists, that patients with diabetes frequently require. “Having that patient cared for in a system that makes it easy to understand what other clinicians are doing and coordinating the care will be good for complex chronic illnesses like diabetes,” she says.
Physicians sometimes are reluctant to hold group appointments for their patients with diabetes because they fear they won’t be able to code and bill for them correctly. Eric Shahady, MD, medical director of the Diabetes Master Clinician Program in Fernandina Beach, Florida, has written extensively about the benefits of group visits and offers the following suggestions on his Web site, www.diabetesmasterclinician.org, from which this is excerpted:
“Without coding the symptom or the diagnosis to show why the treatment was necessary, third parties may not reimburse you for the service. Documentation is the key and most established patients qualify for current procedural terminology (CPT) code 99213 or 99214 if they are properly documented.
A 99213 requires a chief complaint, one to three questions about the patient’s diabetes (frequency and values of self monitored blood sugars, vision, feet, exercise, diet etc.), one review of systems (ROS) question, medical decision-making (MDM) requiring low-complexity care of diabetes, an assessment of controlled diabetes, and a plan that deals with the diabetes. Use a controlled diabetes International Classification of Disesases-9th revision code such as 250.00 for Type 2 controlled, or 250.01 for type 1 controlled. The fifth digit indicates control and the fourth digit indicates complications.
A 99214 requires four questions related to the patient’s diabetes, two ROS questions, and one question about either past med history and or social history. Include in the documentation evidence that the patient is an uncontrolled diabetic not at target and how you will be attempting to bring the patient into control. Documenting the attempt to bring the patient into control satisfies the moderate complexity MDM requirement
Other documentation that indicates uncontrolled and moderate complexity includes some of the following:
1. Numbers that are out of control, such as A1c, LDL, blood pressure;
2. Patient not obtaining eye consult or other consults;
3. Complications are present like retinopathy (dilated eye exam positive), neuropathy (monofilament or vibratory sense decreased), nephropathy (creatinine increased), angina, stroke, chest pain, myocardial infarction, or hypertension;
4. Modifications in their care such as more exercise, diet, eye exam, or urine testing;
5. Increasing a medication dosage or starting a new med, or suggestions for increased adherence to medications;
6. Discussion of side effects of medications, review of drug interactions (note where you found the information);
7. Advice and discussion of how to adhere to lifestyle changes.
For group visits you do not need to do any exam other than vital signs to code a 99213 or 99214 for established patients as long as you have satisfied the history and level of complexity requirements
as indicated above.