U.S. Department of Health and Human Services

National Diabetes Education Program

Align Payment Polices with Care

Payment methods should:

  • Provide fair payment for good clinical management of patients seen.
  • Promote patient centered, effective, efficient, and timely care in a safe environment.
  • Provide an opportunity for health care professionals to share in the benefits of quality improvement.
  • Align financial incentives with the implementation of care processes based on best practices and the achievement of better patient outcomes.
  • Reduce fragmentation of care and not be a barrier to coordination of care for patients across settings.

Clinical Outcomes and Strategies to Achieve Them

Optimal Patient Clinical Outcomes Aligned to Best Practices by Provider and Appropriate Reimbursement for Care
Goal Outcomes Tools and Resources
Patient Strategies Provider Strategies Payer Strategies
Behavior Change

Participate in coaching programs to meet defined lifestyle change goals. Use appropriate modality to meet patient-specific learning style

Utilize community and cost effective resources for support of healthy behaviors

Engage in supportive relationships to encourage and strengthen commitment to behavior change

Identify the need for additional support outside of the medical office and patient needs for ongoing support for behavior change

Create group visit services to build community around diabetes care

Increase frequency of visits for newly diagnosed and struggling patients to help support behavior change

Create reimbursement strategies for team-focused patient care

Allow reimbursement for telephonic, email and text communication as professional services

Create innovative rewards programs for members and providers who achieve desired goals or are progressing towards them

Medication Adherence

Use reminder tools -- email, text reminders, interactive voice response calls triggered by gaps found in medication reconciliation process

Use pill box or auto-reminder pill dispensers programmable for multiple medications and variable timing frequency

Use alert tools in medical record (paper or EMR occurrences) to identify patient medication treatment errors, duplication of class, drug interactions, and medication gaps based on condition or failure to treat to goal

Use electronic prescriptions

Reward practices with appropriate  medication reconciliation processes and increased insulin conversion rates in members not meeting goal A1C

Reduce barriers for insulin pump authorization

Design plans that reward patients and providers for adherence to clinical practice guidelines

Consider medication packets (aspirin, statin, ACE/ARB) that assist members with compliance (PBM)

Consider lowest possible tiers/copays for essential medication for optimal diabetes management and compliance (i.e. insulin pens) such as might be available through plan dosing changes (cSNP programs in Medicare Advantage plans)

Treatment Adherence

Use reminder tools about treatment gaps and need for visits to health care provider

Participate in automated system reviews and action plans for variance

Use Personal Health Record to track treatment and outcomes

Imbed guidelines into electronic health record

Document variance from guidelines clearly

Use baseline tracking tools and action plans for variance from guidelines

Create diabetes registries to track outcomes and align to practice improvement strategies

Increase reward opportunity as percent of patients with clinical outcomes to goal or adherent to scheduled visits increases and availability of provider reduced ED/UC visits

Create meaningful remuneration to account for added skill and time required to support patients by using adherence strategies through quality network designations

Preferentially move patients to high quality, outcomes efficient practices

Continuity of Care

Remain in care at identified primary care practice

Use network facilities and participating providers for extended healthcare needs

Expand operating hours to meet patient needs

Provide after-hours triage and care to prevent unnecessary emergency or acute hospital stays; early follow-up from acute stays

Consider alternates to office visits to manage patient care needs: email, text communications, or blog sites to provide more general healthcare information

Reimburse primary care providers with appropriate specialist referral patterns and reward for practicing at top of licensure

Support home services to encourage early discharge from acute setting

Encourage and compensate for home visits

Coordination of Care

Recognize the physician is not required to manage each healthcare need for a patient

Appropriate access to dietitians, nurse practitioners, podiatrists, optometrists and certified diabetes educator as the extended healthcare team annually is critical to ensuring patients get all their healthcare needs met

Participate in group visits where engagement with others with diabetes can expose patients to new adherence strategies and build confidence in their own management skills

Establish network of best practice providers (a team) to manage the population of patients with diabetes

Ensure timely follow-up after other provider visits and ensure patient understands changes to current treatment plan

Create team grand rounds for challenging patients for healthcare team to ensure maximal clinical outcomes are attainable

Create easy to use online resources to direct patients and practices to area/regional network of preferred care givers

Clearly define member/provider rewardable activities (e.g., annual podiatric evaluation, flu vaccinations, annual eye exam) within network

Support smaller practices with care management support in obtaining referrals and care management solutions