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How to improve diabetes outcomes under value-based care


Good communication and creative thinking can lead to better patient results while boosting doctors’ quality scores

Visitors to the office of Sandra Adamson Fryhofer, MD, might notice it contains a few surprising features.

First are the two yoga mats-one for her and one for her patients-that she uses to demonstrate stretches. Second are the brochures listing local gyms and community health programs. Sometimes she even downloads and prints upcoming gym class schedules during appointments-all with the goal of empowering patients to control their diabetes. 

“When you give people specifics, I really feel that this makes a difference,” she says. “I try to use the office visit as an opportunity to not only talk about what they need to do, but also how they can do it.”

Working diligently to motivate patients-especially those with diabetes-is something that primary care physicians must do if they want to be successful under Medicare payment reform. In particular, physicians must help patients achieve and maintain a healthy hemoglobin A1C level and focus on care coordination with specialists. Doing so helps boost a physician’s Merit-based Incentive Payment System (MIPS) composite performance score, which translates directly to additional reimbursement. 

Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), physicians must persuade patients to take care of themselves, says Tina Colangelo, MHA, a consultant specializing in value-based reimbursement. The question is, how? 

Our experts provide nine tips for improving outcomes and care coordination.


1. Talk about diabetes management 

Even when the purpose of the visit is unrelated to diabetes, it should be a topic of conversation during the visit. 

“If it’s a priority for the doctor, then it becomes more of a priority for the patient,” says Mary Ann Bauman, MD, an internist employed by INTEGRIS Health in Oklahoma who also serves on the Medical Economics Editorial Advisory Board. 

Bauman makes a point of asking about exercise, diet and insulin even when patients present for an ailment such as a sore throat or cough. These conversations keep patients engaged in diabetes management and increase the likelihood of a healthy hemoglobin A1C level.


2. Brush up on communication skills

The goal is to keep inspiring patients to take actions that improve outcomes. Here are three tips:

Start each visit with an open-ended question. Ask patients to identify what’s most difficult in terms of managing their diabetes, says Steven V. Edelman, MD, an endocrinologist and founder of Taking Control of Your Diabetes, an organization that provides diabetes education to patients and physicians. “Then the key is that you have to listen. You can’t interrupt and you also need to have empathy,” he adds. 



Give positive feedback. Congratulate patients when their hemoglobin A1C has come down or when they’re exercising, says Bauman.

Keep an open mind. Don’t make assumptions about patients, advises William Polonsky, Ph.D., CDE, president and founder of the Behavioral Diabetes Institute, an organization that provides patient and physician education about diabetes management. For example, he says, there are many reasons why patients don’t take their insulin. Are they skeptical of the insulin or other medication? Are they unable to afford it? Do they simply forget to take it? 

Remind patients that many people struggle with taking medications and that it’s normal to forget to take those medications from time-to-time. “Help people be comfortable enough to be honest with you,” he adds.


3. Schedule frequent follow-up visits

If weight loss is a goal, consider scheduling appointments every four to six weeks to keep patients on track, says Bauman. This helps keep patients engaged and focused on  maintaining a healthy weight and hemoglobin A1C level, she says. 

Also, ask patients to complete lab tests prior to the visit so you can spend time discussing results face-to-face, says Elizabeth A. Pector, MD, a primary care physician at Edward Medical Group in Naperville, Illinois and a Medical Economics Editorial Advisory Board member. This helps focus the visit and makes the most of the limited time physicians have with patients.


4. Focus on care coordination 

Physicians receive a higher MIPS score when they communicate with specialists and obtain documentation detailing exams or treatments (e.g., diabetic eye exams for retinopathy or neurological screening for neuropathy).  

Ensure that specialists provide copies of their notes. Patients can help by reminding specialists to provide this information to their primary care physician, says Bauman. Enhanced care coordination not only improves outcomes, it also enables physicians to report on additional quality metrics under MIPS.

Medical assistants can obtain copies of specialists’ notes while patients meet with the primary care physician, says Pector. In addition, medical assistants can help patients schedule any overdue specialist exams, she adds. 



5. Consider group visits

Group visits maximize efficiency because they allow physicians to complete certain tasks (e.g., diabetic foot exams or immunizations) for multiple patients at one time. The camaraderie of the group also helps patients feel supported and empowered, both of which can improve outcomes, says Bauman.

When billing group visits, physicians should contact their payer regarding specific documentation and coding requirements. Physicians may be able to report code 99078 for the group education as well as a separate evaluation and management code for each medically necessary one-on-one encounter, says Bauman.

6. Consider hiring a care coordinator

Coordinators help provide the regular and frequent patient outreach that are critical for patients with diabetes, such as reminding them to check their blood sugar twice daily, says Bauman. “This keeps it in the forefront of their minds and helps them maintain better control,” she adds. Physicians receive a lower MIPS score when A1C levels for patients 18-75 years of age are poorly controlled (i.e., hemoglobin A1C is >9%).

Care coordinators can also provide educational seminars for patients. At INTEGRIS Health, for example, two full-time care coordinators lead educational programs for patients who are newly diagnosed with diabetes.  

If a practice can’t afford to hire a care coordinator, consider developing a referral list of  diabetes educators in the community, she adds. These educators also provide patients with a fresh perspective-something that can help when a physician’s own motivational techniques don’t seem to be working. 

Pector refers patients to a diabetes educator when she feels they haven’t made any improvement over the course of several months. “I tell patients I’m not doing my job as their doctor to just keep telling them to try harder with the same approach,” she adds.


7. Use the EHR to your advantage

Some EHRs provide lists of patients with diabetes who are due for office visits or labs. Use the EHR to identify these patients and send automated phone or web messages reminding them to complete labs and schedule appointments, says Pector. 



8. Think creatively 

For example, in terms of exercise, if a patient doesn’t like going to the gym, might he or she be open to using a health or fitness app that tracks diet and activity? If the weather isn’t suited for walking outside, might a patient enjoy walking in a mall?

“Everybody is a little bit different, and you need to be prepared to give patients solutions and strategies that will work best for them,” says Fryhofer. 

To improve medication adherence, consider reducing the complexity of the regimen, says Edelman. Help patients identify the times of day when they are most likely to remember to take their medication and are most convenient to take it. Also, encourage patients to bring a friend or family member with them who can take notes and document solutions discussed during the appointment.

If patients continue to forget, consider an implantable device, says Edelman. These automatically provide the necessary amount of insulin based on the patient’s needs.


9. Provide patient education

Pector educates patients about how blood sugar control reduces the chance of developing small-vessel disease complications such as eye, kidney and nerve damage. 

“I outline basic diet and exercise recommendations, typical follow-up schedule and then refer to our hospital diabetes educators who are excellent resources for initial patient instruction, testing of blood sugar and administration of medication,” she adds.

At Edward Medical Group, several internists and non-physician practitioners have formed a part-time diabetes clinic with onsite diabetes educators, dieticians, behavioral health liaisons and point-of-care testing.

“Our diabetic clinic has usually managed to improve control significantly beyond what our primary care or often consulting endocrinologists have achieved,” says Pector.

When considering patient education, think creatively, says Fryhofer. “As a primary care physician, you have to be ready with information that works for that patient. Everybody is a little bit different, and you need to be prepared to give them solutions and strategies that will work best for them. That’s the joy and the challenge,” she adds.

Knowing your patient population is critical, says Colangelo. Engage patients in a variety of ways, and collaborate with specialists. Doing so will likely have a positive effect on patient outcomes and improve your MIPS quality score in the process, she adds.  

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