Synopsis
The rising rate of diabetes worldwide has in recent years spurred a number of innovative prevention and treatment programs focused on community-based care and information technology. Scaling up these interventions has proved difficult, however. Based on case studies conducted in the United States, Mexico, and India, researchers identified financial, organizational, and regulatory barriers to broader adoption that program leaders and policymakers are struggling to address. The authors believe a combination of new funding approaches, institutional reforms, and performance measures are necessary to spread effective advances in care and reduce the burden of diabetes and other chronic diseases.
The Issue
Diabetes affects 380 million adults, approximately 8.3 percent of the world’s population. Recognizing that widespread improvements in health will likely require “disruptive” innovations in prevention and treatment, a number of programs have emerged to combat diabetes through nontraditional pathways. These efforts include bundling care with nonhealth services, providing treatment in community settings, and using technology to reach isolated or homebound patients. Scaling up or extending these new care models has proved difficult, however, owing to a host of institutional, regulatory, and financial hurdles. Writing in Health Affairs, Commonwealth Fund–supported researchers examined transformative innovations in diabetes care, using case studies from Mexico, India, and the U.S., countries where diabetes prevalence is higher than the global average.
Diabetes Care Innovations in Mexico, India, and the United States
"Disruptive innovation for diabetes care is not easy, but it is essential to reducing the rising health and cost impact.”
"Disruptive innovation for diabetes care is not easy, but it is essential to reducing the rising health and cost impact.”
- Pro Mujer, in Mexico, integrates health and financial services for low-income women. For instance, it provides diabetes screenings, education, and other health services at reduced cost to women who attend monthly microloan repayment meetings.
- ClickMedix, which operates in all three countries, provides virtual medical consultations to vulnerable and rural patient populations. The electronic platform enables health workers to serve more patients while lowering costs.
- The YMCA Diabetes Prevention Program uses existing community-based centers to reach patients, coordinating exercise and providing health education, nutritional support, and individual counseling at YMCA sites across the U.S. It has been expanded through results-based, add-on payments made by UnitedHealthcare and Medicaid. Depending on an individual’s attainment of weight-loss goals and class attendance, the program receives $175 per person per session on average. These payments have allowed the YMCA to offer the program to people who otherwise could not afford it or who are not covered by a participating insurer.
Policy Reforms to Reduce Barriers
The authors identified financial, institutional, and regulatory policy barriers that have hindered the diffusion of these and other successful care innovations:
Financial barriers. Across the three case study examples, financial barriers proved to be most critical. “There was a poor fit between the new models of care and many existing payment policies,” the authors note. For instance, in the U.S., estimates from the Diabetes Prevention Program suggest that scaling the intervention could delay 885,000 new cases of diabetes and save $5.7 billion over 25 years. Yet large agencies like the Centers for Medicare and Medicaid Services (CMS) and the Department of Veterans Affairs are currently unable to redirect funding to adopt this model. Thus far, only a limited set of private payers have done so.
Institutional barriers. Pro Mujer in Mexico is dealing with issues related to health services regulation under the finance ministry, as its diabetes program is operated in conjunction with financial services outside the traditional health system. In the U.S., the fragmentation of public financing across different agencies, such as CMS for diabetes care and the Centers for Disease Control and Prevention for community initiatives, is a complicating factor. In India, meanwhile, the state-based nature of regulation and financing “complicates the nationwide adoption of new care models,” the authors say. Program leaders have responded by developing collaborations with physician groups and other providers, public health and patient advocates, and business and insurance leaders, as well staff members in key government agencies. Based on their research, the authors say that innovation usually begins and is scaled up in the private sector, “because partnerships with the public sector can take time to develop.”
Regulatory barriers. In Mexico, the Pro Mujer program found a lack of clarity about which agency had jurisdiction over the program. In the U.S., differing state laws created challenges related to licensing and practicing medicine across state lines. Regulatory barriers were relatively low in India.
Overcoming Barriers to Diffusion
The authors identified policy reforms that would provide health care innovations with a “clearer pathway to sustainability.” Most important are financing reforms, such as linking provider payment to scores on “meaningful, outcome-oriented” performance measures, offering add-on payments to providers, or making subsidies available to patients. Other recommendations include forming partnerships between health care payers and community organizations.
About This Study
The authors conducted a literature review to identify diabetes care innovations in different countries. Once selected, they interviewed some of the organization leaders (i.e., of ClickMedix and Pro Mujer) regarding barriers and challenges to adopting and disseminating their programs.
The Bottom Line
“Disruptive innovation” in diabetes care is essential in the fight against this costly global disease, but financial and other policy barriers must be overcome if the most promising programs are to reach those populations most likely to benefit.