In an effort to reduce Medicare costs, CMS included diabetes mail-order supplies in its April 2 final rule on competitive bidding. Diabetes supply providers argue that this price-driven strategy will prove even more costly to Medicare in the long run—because it overlooks the important role providers play in patient education and empowerment. If competitive bidding edges out smaller providers or forces them to abandon educational services, providers believe that patient compliance will drop, and costs related to diabetes complications will skyrocket when there is no one left to fill that void.

Newly diagnosed patients embark on a steep learning curve. For Medicare patients, certified diabetes educators (CDEs) cover topics such as making menu choices, managing medication, maintaining foot care, and using equipment. Although they are not reimbursed for these sessions, diabetes supply providers such as Mark Gielniak, VP of Diabetes Plus, Warren, Mich, often participate in these programs at local hospitals. "Patients get 2 hours with a dietician and a CDE, and then they get 8 to 10 hours of classroom training," he says. "There are five or six different instructors that come in as part of this one program, and we teach them about all of the different aspects of how to lead a healthy lifestyle."

Sometimes, patients do not even accept the diagnosis. "With Type 2 diabetes, a lot of it is weight-related, and patients are frustrated because if they were taking better care of themselves, they may have prevented this or at least postponed it," Gielniak says. "This is not one of those diseases that you can just take a pill and it goes away. A lot of them have a hard time accepting the longevity of it."

Educational sessions provide a vital foundation in diabetes management, but the information needs to be reinforced. "When people are diagnosed, they are in a state of shock," says Glenn Brosnick, founder and CEO of Diabetic Plus, Sunrise, Fla. "They're bombarded with information. They don't grasp it."

Patients are also terrified of complications affecting the eyes, feet, and heart—and often despair that these conditions are inevitable. These and other misconceptions are symptomatic of a surprising lack of knowledge about the disease itself, according to Brosnick, who says that there are few resources that explain diabetes in terms that average people can grasp quickly. To help his customers bridge the knowledge gap, Brosnick uses a metaphor that compares sugars in the body to gasoline in a car. "It gives them a very good idea about how to watch what they're eating," he says. "The problem is that diabetics have too much sugar—too much fuel in their fuel lines. And when you explain to them that the fuel gauge is the glucose monitor, it becomes clear to them."

SUPPLYING SUPPORT

Patients often look to diabetic supply providers to give them the information they need about day-to-day disease management. Reassuring newly diagnosed patients about their ability to manage the disease comes with the territory. "Part of our education process is not only showing them the equipment, but also letting them know that through the proper management of diet, testing, exercise, and medication, it can be properly managed, and you don't necessarily have to end up with complications," Gielniak says.

To drive this message home, many providers take extra steps that they pay for out of their own pockets. Gielniak will make personal deliveries, especially on the initial visit, to solidify relationships with patients, and will even drive out to customers who need help replacing a battery or just to reset the clock for daylight saving time. He also spends as much time as patients need making sure that they feel comfortable with the equipment, and he involves them in the choice. "We open up the products to them, so that they have some control over it," Gielniak says. "Part of managing diseases is having some control."

Karen Kaczmarek

Eventually, all type 2 diabetes patients require insulin injections, and Gielniak works with these patients to help them overcome their fears. "If it was in a pill form, they would take it gladly," he says. "But they just have a fear of actually having to inject it. We try to make them feel relaxed. Once you show them the proper way to do things, you can put their minds at ease. They can stop being nervous about testing. They realize it's not hard, it's not painful. And that is a big step in being compliant."

Brosnick sends all new patients a two-disc video he produced called the "Diabetes Home Video Guide: Skills for Self Care," which covers everything a patient should know to live healthily, from the details of insulin production in the body, to nutrition and exercise. Brosnick always drives home to patients that they need to take control of their own care; they can't rely on their doctors to do it for them.

Mark Gielniak

Part of the service model for providers is offering patients service whenever they need it. This is accomplished in a variety of ways—especially by providing face-to-face visits with patients and having knowledgeable staff available to answer questions over the phone day and night.

Brosnick learned the importance of this access firsthand, when his son, Koby, was diagnosed with type 1 diabetes at the age of 3 in 2003. "As a parent, you're in a state of shock," he says. "Your child has just been diagnosed with a lifelong disease, no cure, and you now have to figure out basically how to keep this child alive."

After many experiences of being put on hold, Brosnick decided to found his own company that would always have a knowledgeable person answering phones. "Diabetes is a disease that is 24 hours a day, 7 days a week," Brosnick says. "I think if you're going to be responsible for diabetics and doing their supplies and education, you should always have somebody answer that phone."

Having knowledgeable phone representatives is also important at Diabetic Supply, Pompano Beach, Fla. While company reps provide initial equipment training to patients in their homes, the majority of customer service takes place over the phone. "Most people are very satisfied with being able to get support via the telephone," says Karen Kaczmarek, director of compliance. "Especially with the Medicare population, when they find a particular customer care representative that they enjoy talking to, they always want to talk to that person. They tend to develop a relationship and feel comfortable with that person."

Diabetes supply providers are not reimbursed for their educational role—equipment training is supposed to be covered as part of the fee for the equipment itself. Gielniak says the interpretation of this training varies greatly. Some companies provide only the training manual. Others, like Diabetes Plus, offer patients face-to-face support whenever they need it. "We get paid the same as everybody else," he says. "But I think we give people more for their money."

UNCERTAIN FUTURE

No one knows for sure what competitive bidding's impact will be, but most providers expect the process will force smaller companies to fold, leaving a few bigger mail-order players to handle the patient load. Providers like Gielniak are faced with the reality that they may have to drop out of the Medicare business altogether in a year or two, if they cannot keep up with the aggressive cuts.

One bright spot for the diabetes industry is the technology itself. Today's meters require smaller blood samples, which are less invasive to patients. This means thinner lancets can be used, and today's needles can be adjusted to many different levels of penetration depth. Some meters have even been approved for alternate site testing. "So, instead of pricking their fingers, which can be painful after a while, patients can prick other areas such as the palm of their hand or their forearm," Kaczmarek says. "I think technology will hopefully continue to improve so that it becomes less of a process for patients."

Gielniak worries, however, that competitive bidding will stall technology. "Technology costs money," he says. "And if there's not going to be money in the sale of meters or strips, then [companies will] be looking to take existing technology and just make it less expensive to produce."

There is also the concern that companies will have to offer cheaper, lower quality products to compete. While Detroit is not yet affected by the current ruling, Gielniak is making plans. "If we are allowed to provide at bid price, we will do it," he says. "I have been looking at alternate products that would be lower cost, but the quality is still fairly good. In a case like that, if we do not have to do a volume [sale], we'd probably still do some type of training."

A concern prior to the final rule was that patients would be forced to switch meters if the winning bidder decided to offer test strips for a different brand. The final rule alleviates some of those concerns. "The strips are meter-brand-specific," Kaczmarek says. "Meters aren't all the same, and there are different reasons why you'd use different meters with different patients. They have put some rules around protecting the patient from having to switch."

In many ways, the business rests in the hands of bidding providers. "One would hope that when suppliers bid, part of the bid includes the amount of training that is typically required," Kaczmarek says. "You can't just consider the product costs."

Ann H. Carlson is a contributing writer for  HME Today.