ARIZONA
HOUSE OF REPRESENTATIVES
Forty-third
Legislature - First Regular Session
STUDY COMMITTEE
ON MANDATORY INSURANCE
FOR
DIABETES TREATMENT
Minutes of Meeting
Thursday,
October 30, 1997
House
Hearing Room 2 - 9:00 a.m.
(Tape 1, Side A)
The meeting was called to order at 9:13 a.m.
by Chairman Marsh and attendance was noted by the secretary.
Members
Present
Dr. Richard Dolinar Ms.
Voss
Mike Minnaugh Dr. John Yao
Mrs. Preble Mr.
Marsh, Chairman
Christian Sumner for Wilbur Pittinger
Members
Absent
Mr. Jackson
Mr. Nichols
Speakers
Present
Jodi Jerich, Research Analyst
Dr. Philip Levy, representing American
Diabetes Association (ADA)
Dr. Joel Brill, Chief Medical Officer, Gila
River Health Care Corporation, Sacaton
Sue Glawe, Administrator, Government
Relations, Blue Cross Blue Shield of Arizona
Steve Barclay, Lobbyist, representing CIGNA
Gloria King, representing herself
Sue Hendershott, representing American
Diabetes Association; American Association of Diabetes
Educators, Fountain Hills
Guest List (Attachment 1)
Chairman Marsh introduced
the Members. He explained that the
Committee will be considering mandatory insurance coverage for diabetes
treatment, and speakers will provide an overview regarding diabetes, treatment
protocols, and current coverage of insurance companies.
Jodi Jerich, Research
Analyst, provided an overview of a handout regarding the charge of the
Committee and related legislation enacted in the states of Nevada, New Mexico,
Indiana, and Texas, as well as a Texas Pilot Program (Attachment 2). She noted that the Arizona Health Care Cost
Containment System (AHCCCS) covers all diabetic services, equipment, laboratory
work, classes, and preventative care that is medically necessary. All state employee Health Maintenance
Organizations (HMOs) cover diabetic equipment, supplies, treatment, and
education that is medically necessary.
CIGNA and other indemnity plans provide diabetes coverage as a writer so
it is not included in the basic health care premiums.
She conveyed the fact
that funding for diabetes research has increased 310 percent since 1993. Recently, $819 million was provided to the
National Institute of Health (NIH), and $28 million to the Center for Disease
Control and Prevention. Furthermore,
the Balanced Budget Act recently included two grants for diabetes treatment for
which states can apply: $30 million
grant for treatment of Type I diabetes in children and a $30 million grant
through Indian Health Services.
Referring to the Indiana legislation, she clarified for Mrs. Preble that
Medicaid is excluded (see first page of Senate Enrolled Act No. 184 [Attachment
2]).
Dr. Philip Levy,
representing American Diabetes Association (ADA), spoke in favor of the
proposed mandated legislation. He
testified that diabetes is a major health problem and a nightmare for health
insurance plan administrators because of associated expenses and
complications. It is estimated that
about 18 million people in the United States have diabetes, and about half of
those are not aware of it. It is
estimated that about 280,000 people in Arizona have diabetes. The disease is more common among Hispanics,
North Americans, and Black Americans.
He remarked that it is the leading underlying cause of heart disease,
blindness, and nontraumatic foot and leg amputations in adults. It also leads to kidney disease and kidney
failure.
He indicated that
diabetes is a disease where care can be accomplished by educating the patient
to manage his/her own care. He said the
statement that insurance plans cover education can be somewhat misleading if
the education is provided by the doctor only.
He noted that diabetics can properly manage the disease by testing blood
sugar levels. Test strips are
expensive, and most diabetics must test several times a day, some four, five,
or six times a day. .
Dr. Levy advised the
Members that a Diabetes Complications and Controls Trial (DCCT) study funded by
an NIH grant for approximately $165 million over ten years showed that if
diabetes is tightly controlled, the incidences of complications diminish 50 to
75 percent. Many outcome studies show
that careful care, self-management, and education of patients definitely
decreases problems. He noted that the
cost of complications is horrendous and affects production in the
workplace. It is estimated that
diabetes nationally costs $450 billion per year, including direct and indirect
expenses.
Dr. Joel Brill, Chief
Medical Officer, Gila River Health Care Corporation, Sacaton, testified in
support of mandated legislation. He
indicated that the Corporation represents health care for the Pima Indians, who
have a very high incidence of diabetes.
The cost for treatment of dialysis, amputations, heart disease,
gestational diabetes, etc, is staggering.
He indicated that there is a tremendous variance in the way health plans
pay for diabetes care, education, self-management, the use of testing, etc.,
but the Corporation is fortunate in that it is able to pay for diabetes
educators. He speculated that everyone
has a family member, friend, etc., with diabetes who suffer from complications
and submitted that those people deserve the opportunity for appropriate
measures of treatment and education that has been offered to almost half the
states in the union. He informed Ms.
Voss that the Corporation offers
education for diabetics because it has been shown by programs, such as
the DCCT, that a team-based approach involving physicians, podiatrists, nurses,
diabetic educators, etc., reduced the rate of limb amputation by 85 percent in
five years= time.
He related to Mrs. Preble that all people, including those of
Medicaid-age, are treated in the same fashion by the Corporation.
Mrs. Preble stated that
those people diagnosed in their 40's and 50's are the ones who have amputations, kidney problems, etc.
(Tape 1, Side B)
Mrs. Preble noted that
one of the states denied sight benefits, which is not rational, since it is a
problem associated with diabetes.
Sue Glawe, Administrator,
Government Relations, Blue Cross Blue Shield of Arizona, testified that both
the PPO Indemnity and HMO products cover all diabetes-related supplies,
equipment, and treatment, with the exception of education and counseling. Blue Cross is under National Committee on
Quality Assurance (NCQA) certification, and part of that process is to identify
two case studies. Diabetes is one that
has been identified, and NCQA is placing rigorous demands on the study (such as
followup care, education, and nutritional counseling).
Dr. Levy commented that
diabetes management and training are not included in Blue Cross coverage but
that probably will change due to NCQA requirements and guidelines from the
American Diabetes Association (ADA). He
submitted that he has had ongoing arguments with Blue Cross for many years
because it does not believe that education is a necessary process in taking
care of the patient. Ms. Glawe remarked
that Blue Cross currently makes education and counseling referrals on a
case-by-case need but she believes that will be expanded very soon.
She clarified for Ms. Voss
that under recently passed Congressional legislation, a person with a
pre-existing condition who moves to another company is covered not only for
diabetes but all conditions, as long as the credit time is met. Ms. Voss asked if coverage is available for
a person diagnosed in his/her 30's who becomes disabled in his/her 40's and can
no longer work. Ms. Glawe expressed a
hope, depending on the person=s income level or level of disability, that coverage would be available
through the Arizona Health Care Cost Containment System (AHCCCS) or
Supplemental Security Income (SSI). She
related to Mrs. Preble that she will find out what criteria is required before
referral is made by Blue Cross to a nutrition counseling center.
Steve Barclay, Lobbyist,
representing CIGNA, expressed appreciation for the intentions of the speakers
who have provided good arguments for treating diabetes. He stated that CIGNA has done much in this
area but maybe not as much as advocates would like. He said it appears that some improvement regarding education may
be necessary but submitted that there is a limit on how much companies can be
mandated to deliver certain services if members do not take advantage of the
ability. He expressed a concern that a
mandate will have unintended consequences and pointed out that when state
mandates are made, only about 35 to 38 percent of the covered population is
affected because the uninsured, AHCCCS and Medicaid populations, Indian
communities, and self-insurers under the Employee Retirement Income Security
Act (ERISA), are not included. This
creates an unlevel playing field and disparities. In the small group market, particularly, there is a potential for
driving employers out of providing coverage altogether, i.e., if a premium goes
up even incrementally, some will drop coverage. He concluded by stating that
the Committee=s objective can be accomplished in a more
effective manner than imposing a mandate on insurance companies.
Ms. Voss asked if CIGNA
or anyone else has conducted a study to determine if costs would increase if
mandated legislation is passed and if overall costs would increase or decrease
by practicing preventative measures on the front end. Mr. Barclay replied that he does not know the answer but will
attempt to obtain figures but the precise mandate would have to be determined
in order to obtain accurate data. He
said, hopefully, there could be savings on the back end. He speculated that there is a danger, even
if it would be cost effective, that it will be difficult to stop micro-managing
health care. Ms. Voss asked if costs have increased in those states that have
passed this legislation. Ms. Jerich
indicated that the figures are not yet available.
Dr. Yao stated that he is
the Associate Medical Director for CIGNA in Phoenix. He commented that a mandate may not necessarily be effective if
patients do not have an interest or understand their responsibility. He related that CIGNA has a diabetes health
education team that provides health education to patients at no cost, and every
time a new diabetic is diagnosed, the patient is immediately referred to that
team. Virtually all necessary treatment
and care relating to diabetes is covered by CIGNA due to the economic
consideration that the better a patient is managed, the healthier the patient
will be. He indicated that there is a
great deal of private sector competitive free market pressure already driving
this process, and he believes that will continue. He mentioned that when special groups lobby to mandate specific
activities, it can become problematic to practicing physicians and health plan
administrators. If every group begins doing that, the situation can become
uncontrollable.
Dr. Dolinar remarked that
doctors treat complications of diabetes while patients treat diabetes. He explained that in Type I, juvenile
diabetes, the pancreas, which makes insulin, is damaged so insulin injections
are required. In Type II, insulin
produced by the pancreas is not used effectively, resulting in high blood
sugar. Complications occur as a result
of high blood sugar. He indicated that
a DCCT study showed that proper blood sugar control decreases complications of
diabetes. In order to maintain good
blood sugar control, patients must follow a special diet, exercise, and inject
themselves with insulin. Referring to
the economics of diabetes care, Dr. Dolinar noted that Richard Eastman with the
National Institute of Health (NIH) gave three presentations on the cost of
diabetic care and suggested that the Committee obtain some of his writings or
request that he make a presentation. He
added that a Study of the Cost of Mandated Benefits in the Insurance Issues
Paper (Office of the Commissioner of Insurance) may be helpful to the
Members.
Dr. Dolinar conveyed to
Mrs. Preble that it is absolutely critical to teach patients how to handle
diabetes, and many times it takes a team effort. Once a patient is educated, access to supplies to treat the
disease is necessary. Historically, a
diabetic was not treated by a physician for many years until complications
developed. If diabetics obtain proper
education and tools, it will definitely make a difference.
Dr. Yao agreed that
treatment of diabetes is up to the patient and acknowledged that good control
of blood glucose is definitely desirable for a diabetic. He reiterated the fact that CIGNA patients,
once diagnosed with diabetes, are immediately referred to a diabetes education
team so the patient=s care
is coshared by the patient and the team.
Usually the team does more for the patient than the physician.
Mrs. Preble stated that
at the next meeting she would like to know what coverage is offered by health
plans in Arizona and what is needed to encourage, versus mandate, those that
are lacking. Chairman Marsh noted that
the Managed Care Association will provide some information to the Committee.
Gloria King, representing
herself, stated that she is a certified diabetes educator and a 59 year-old
survivor of Type I juvenile onset diabetes.
She indicated that diabetes care cannot be mandated. She made a promise to her father, mother,
and God to be of service if she can live a long productive life. She contended that patient care and
education is important, and if she had not received the care of a competent
endocrinologist, she would not be alive today.
Patient education, nutrition counseling, and appropriate supplies are
cost effective and cost beneficial. She
said this year she has her first complication, cataracts, which, fortunately,
can be removed and lens replacements made.
She acknowledged that the DCCT program did work and was cut off early
because it was so successful.
Dr. Dolinar commended
Mrs. King for managing her diabetes care so well. He added that prior to 1922, patients diagnosed with Type I
diabetes died within six months to two years.
In 1922, insulin was discovered, and people began living longer. He indicated that Mrs. King is an excellent
example of a patient properly caring for diabetes.
(Tape 2, Side A)
Mrs. King informed Ms.
Sumner that certified diabetic educators must take a national certification
examination every four years. It is
important to have a diabetic education nurse as well as a diabetic education
registered dietician. The nurse works
with the patient on medication and blood sugar levels, how to take medication,
and sick day rules. The dietician
prepares an appropriate food plan.
Ms. Sumner asked how
different types of insurance plans reimburse diabetes educators who are not
nurses but dieticians, and whether or not there is difficulty in obtaining that
reimbursement. Mrs. King answered that
there is difficulty obtaining reimbursement.
She worked for an HMO in the Washington, D.C. area, which was one of the
few that actually paid for registered dietician services. More frequently, nursing services are
reimbursed.
Chairman Marsh also
commended Mrs. King, noting that diabetes management is a difficult process,
especially for juveniles.
Mr. Minnaugh stated that
he has the unfortunate responsibility of being the parent of a diabetic child.
As the President of Peak Insurance Group, he asked his employee benefits unit
to consult with numerous companies about available coverage for diabetics. He remarked that the larger the group, the
less complicated and difficult it is to obtain insurance. The unit reviewed ten major insurance
companies in the state, and there is a significant difference in every
one.
He indicated that his
family insurance company does not pay for test strips, which probably cost $70
to $80 per month, nor lancets to prick his son=s finger to test his blood.
Fortunately, he can afford that but not everyone can. He speculated that many people do not test
properly because of the cost. He stated
that it was terrible when his son was diagnosed at age ten. At age 12 or 13, his son attended a camp in
northern Arizona sponsored by ADA. It
was very expensive and not covered by any insurance company. However, the camp was very beneficial for
his family and son in treating and understanding the disease. His son was taught how to give himself shots
and learned that he is not alone. Mr.
Minnaugh submitted that something should be done to expand the coverage that is
available and make it affordable. He
related that one major insurance company covers diabetics in a group but the
charge is $5,000 per diabetic without obtaining any information about the
patient. He indicated that he doubts if
actuaries are up-to-date on diabetes research or that underwriters have any
idea of the advances that been made. He
added that it is also difficult to obtain life insurance for diabetics.
Mr. Minnaugh commented
that he is a member of the board of the Juvenile Diabetes Foundation, whose
goal is to raise money to find a cure for diabetes, but, in the meantime, he
has to raise his son. His son uses
literally thousands of alcohol swabs and tests his blood sugar six to eight
times per day. He is a competitive
swimmer, and during that season, must test it even more. He said not all syringes are covered, and
they are not cheap. While there is some
coverage available, it could be improved.
He added that he does not like the word mandatory either but it may be
necessary to protect the citizens and children of this state.
Sue Hendershott,
representing American Diabetes Association (ADA); American Association of
Diabetes Educators, congratulated the Committee on its efforts. She indicated that 3.9 percent of Arizona=s population is diagnosed with diabetes, and
probably an equal amount are undiagnosed.
In 1994, it cost $1.3 billion for care of patients with diabetes and
related complications. She submitted
that coverage for supplies is irregular.
She conveyed the fact that a major issue addressed by the federal
government last year was the fact that people with Type I diabetes (about 10
percent of the diabetic population) generally have coverage which pays for test
strips but people with Type II diabetes (about 90 percent of the diabetic
population) do not. In the Omnibus
Budget Act last year, Congress declared that test strips, equipment, supplies,
and education for people with Type II diabetes will be covered beginning
January 1998; therefore, the Medicaid population will be taken care of.
She noted that she is a
Member of the ADA Government Advocacy Committee which has studied coverage for
supplies and education. It has been
found that even though insurance companies say that education and supplies are
covered, when a patient actually tries to access that coverage, it is very
difficult to do. She related to Ms.
Voss that a study was conducted in the
State of Maryland in 1991 in which comprehensive diabetes care involving education
and supplies was provided to a Medicaid-type population. Within a two-year period of time, a $4,500
per person savings was realized because hospitalization rates decreased, as did
in-hospitalization and emergency room visits.
She indicated that she can provide that information to the
Committee. She concluded by stating that
expanded coverage for supplies and education for people with both types of
diabetes would be beneficial to Arizona, which will encompass more and more
people with diabetes as the state grows and the population ages.
Mrs. Preble asked if
studies have shown how helping an insulin dependent diabetic remain stable
would impact Long Term Care (LTC) in Arizona.
Ms. Hendershott stated that a post- DCCT study reviewed the savings over the lifetime of a person with Type I
diabetes. She does not know that number
but she will be happy to provide it.
Ms. Voss stated that she
would like to know the definition of Amedically necessary.@ If insurance plans and
physicians are not in agreement, the issue should be dealt with, possibly
avoiding a mandate. She surmised that
Arizona Long-Term Care System (ALTCS) patients probably have a high incidence
of diabetes, and some cannot even read the meter to test blood sugar levels.
Dr. Yao said the DCCT
study, which primarily involved Type I
diabetics using intensive therapy with multiple injections per day and insulin
pumps, showed that the average cost is three times higher than conventional
therapy. A key issue to be mindful of
is that 90 percent of diabetics covered
are Type II, and the majority tend to be overweight. The cornerstone therapy is exercise, appropriate dieting, and
weight reduction, which cannot be mandated.
He said if patients do not take responsibility, a great deal of success
will not be realized.
Dr. Dolinar acknowledged
that the DCCT study was conducted on individuals with Type I diabetes, noting
that for both types, high blood sugar results in complications. He said the endocrine community believes
that the results of the DCCT trial also apply to people with Type II
diabetes. Dr. Yao agreed with the
conclusion that good glucose control is beneficial when applied to both groups.
Dr. Dolinar stated that diet is absolutely critical in controlling diabetes;
however, he does not encourage his patients to lose weight. It is common knowledge that weight is
genetically based, and it is wrong to imply that someone is not attempting to
care for diabetes because he/she is overweight. He said he looks for cancer when a patient is losing weight, and
many times it is found.
Chairman Marsh indicated
that more meetings will be held.
Without objection, the
meeting adjourned at 11:20 a.m.
______________________________________
Linda Taylor, Committee Secretary
(Original minutes,
attachments, and tape are on file in Office of the Chief Clerk.)
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DOCUMENT FOOTER ---------
STUDY
COMMITTEE ON MANDATORY
INSURANCE
FOR DIABETES TREATMENT
OCTOBER
30, 1997
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DOCUMENT FOOTER ---------