The growing challenge of managing diabetes in primary care settings

As diabetes becomes increasingly common in the United States (affecting 38.4 million Americans and growing steadily), diabetes health outcomes are stagnant or worsening. As identified in a report published in The Annals of Family Medicine, these shortcomings can often be attributed to an insufficient number of endocrinologists and increasing burdens on primary care professionals (PCPs), who treat more than 90% of cases, currently. These burdens are often the result of a limited workforce, misaligned payment systems and disparities in care access for underserved populations. Researchers made several policy recommendations intended to strengthen primary care with team-based models, expand and support the primary care workforce, institute payment reform and address social determinants of health (SDOH).

“It is evident that rapidly growing numbers of Americans with diabetes rely on primary care for diabetes management, and PCPS, who are in short supply, have limited resources to meet this challenge,” the authors of the study wrote. “Where PCPs work in teams that expand opportunities for interdisciplinary collaboration and community partnerships, access to care, diabetes self-management and patient outcomes improve. But advanced, team-based primary care cannot flourish when clinicians lack resources, training and support.”

Researchers pointed out that policy solutions aimed at addressing challenges in the nation’s primary care system have been proposed and tested for decades, although their long-term impact has been stunted by underinvestment. Additional challenges specific to diabetes management in primary care settings surround the complexity of diabetes care. It’s common for patients to develop comorbidities, including hypertension and kidney disease, which increase the demands of treatment plans. Insufficient staffing, limited time and misaligned payment systems can also prevent PCPs from delivering comprehensive and coordinated care, specifically in marginalized, underserved communities.

Prioritizing team-based care

Researchers recommend placing emphasis on team-based models as the first step to strengthening primary care. They reference studies published in Population Health Management and the American Journal of Preventative Medicine which demonstrate the clinical benefit of team-based approaches to care for patients with chronic conditions, including diabetes.

Specifically, the report recommends the implementation of chronic care model (CCM) and patient-centered medical home (PCMH) approaches to improve health outcomes. “[CCM] brings together communities, health systems, self-management support, care delivery systems, decision support and clinical information systems to improve care for people with chronic conditions,” the authors explained. The PCMH approach establishes a primary care model which prioritizes comprehensive, person-centered, coordinated and accessible care, enhancing relationships between patients and primary care teams, according to the report.

The researchers also recommend leveraging non-physician clinicians, including nurse practitioners and pharmacists, and encouraging integrated training and partnerships to ensure the standardization and optimization of diabetes care delivery.

Developing an adequate workforce

To ensure the success of team-based care models, they should be fully staffed with a range of health care professionals. There are federal policies which can increase the likelihood of a medical student choosing to specialize in primary care. The researchers believe that more should be done to broaden the financial pathways to support students’ choice of primary care. For example, existing programs like the National Health Service Corps could be expanded by Congress, thereby increasing loan forgiveness for physicians and other health care professionals who enter and remain in primary care practice.

Similar steps can be taken to increase the number of PCPs who practice in underserved or rural areas. It would also be beneficial to bolster resources for primary care teams to enable comprehensive diabetes care and self-management education.

Instituting payment reform

Researchers recommend that policymakers promote team-based primary care by increasing reimbursement for all members of the primary care team, including community health workers and care navigators. Enhanced payment models should emphasize care coordination and partnerships between PCPs, specialists and community resources.

The report emphasizes the important role that pharmacists play in diabetes management, recommending that they be reimbursed for their services, including prescribing continuous glucose monitors (CGMs), which are crucial for diabetes management. According to the researchers, by expanding pharmacists’ prescribing authority for CGMs and funding their services through Medicare, patient outcomes could be significantly improved.

Addressing social determinants of health (SDOH)

The report references a 2021 article published in the Journal of the American Medical Association which demonstrated that, among diabetic people, individuals that were from “racial and ethnic minority groups were substantially less likely to attain high-quality diabetes care.” Researchers recommend targeting disparities in access to care for racial and ethnic minorities and rural populations through Medicaid reforms and culturally tailored interventions. Also, in order to improve access to high-quality diabetes care for racial and ethnic minority groups, there should be more practitioners in primary care settings who are from racial and ethnic minority groups themselves.

“Lack of trust in the health care system and medical professionals can hinder care for these groups, and studies show that having a professional of the same race or one with whom a person identifies can reduce mortality,” the authors wrote.

For the nearly 12% of Americans who have diabetes, it is evident that primary care systems, as they currently stand, are not optimized for diabetes management. Without proper resources, training and support, there is no way for PCPs to reach that point.

“There is a measure of urgency for policy leaders to create or expand programs to attract, train and retain health care professionals, deploy PCPs to rural and historically underserved communities and tackle financial incentives, regulatory hurdles and social care shortcomings that impede a robust, national network of primary care teams resourced to address the full spectrum of care needs of people with diabetes,” the authors concluded.