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DIABETES AND
OBESITY

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the management of the patients assigned to the group by the MA patients. There is, in fact, evidence that higher HMO penetration,
plan. Thus, there is a financial incentive for the medical groups to in both Medicare and commercial, has positive spillover in the
assure the patients are not just receiving care; however, receiving management of patients. There is a simple explanation for this.
care that produces an improved outcome. Take type 2 diabetes as doctors tend to practice medicine in a rather consistent manner.
an example. That is a good thing! And when they develop positive patterns of
In 2012, it was estimated that more than 21.8 million Americans practice that are imposed upon them by managed care plans, they
had type 2 diabetes. The majority of those were between the ages tend to adopt the practice patterns on non-managed care plan pa-
of 46 and 64 (44 percent), and 65 and older (43 percent). As with tients as well. Studies suggest that over the past decade that the
many disease progressions, age is indeed an independent risk fac- MA plans have improved the performance of TM members as a
tor for the acquisition of disease. Regarding race/ethnicity, 60 per- result of the "spillover" effect of managing the care of these pa-
cent were non-Hispanic white, 17 percent were Hispanic, 15 tients through population health management techniques. The
percent were black, 5 percent were Asian, and 3 percent were oth- comparisons of quality between MA and TM tend to favor MA.
ers. Individuals with a high school diploma, the unemployed, and Furthermore, there is evidence of spillovers from MA to TM,
those with incomes below $20,000 accounted for over half of which may justify a higher reimbursement rate for MA.
those with diabetes. About 41 percent of diabetes cases were from Managed care can influence physician practice styles more
the southern census region, and 83 percent were from urban areas. broadly if managed care changes the physician treatment of man-
And as we all know, type 2 diabetes is often associated with aged care patients, and then those changes affect the physician’s
some other health conditions that lead to a deterioration of indi- treatment of his or her other patients. We have witnessed over the
vidual health. Heart disease, vascular compromise, diabetic foot years that the method of reimbursement does influence the prac-
ulcers, blindness, high blood pressure to name a few of the co- tice patterns of providers including hospitals. The number of bed
morbidities associated with type 2 diabetes. So why do MCOs help days/1,000 were substantially reduced when CMS converted the
in managing this disease, particularly in the Medicare population? reimbursement form a Fee-For-Service (FFS) to a prospective pay-
On average, MA plans appear to offer higher value than Tradi- ment diagnostic Related Groupings (dRGs). Managed care plans
tional Medicare (TM), and often there is a positive spill from MA deploy many techniques to control utilization, such as pre-autho-
into TM that suggests that reimbursements effect management of rization, utilization review, referral requirements, restricted net-

26 San Antonio Medicine • December 2018