Lessons in diabetes care from Spain, India, Mexico and the U.S.

Type 2 diabetes (diabetes mellitus) is one of the most common chronic diseases worldwide and requires coordinated care and active patient engagement for effective management. The disease affects 380 million adults around the world or 8.3 percent of the global population. The prevalence of diabetes around the world is projected to continue to rise with increased globalization and the resulting behavioral changes, nutritional shifts, and aging populations.

Around the world, a range of programs are attempting to confront this growing trend by implementing care transformations that support prevention and disease management.  At the same time, health systems have been under mounting fiscal pressure to reduce health care costs. Yet, many countries, including the United States, still struggle to support and sustain effective diabetes programs. 

Four common challenges in diabetes care around the world 

To assess how health systems were implementing and sustaining innovative diabetes programs, the Brookings Institution conducted five global cases studies in Mexico, India, Spain, and the United States to examine clinical and financial models for transforming diabetes care.  Given the impact of behavioral choices on the disease, all of the diabetes programs rely heavily on patient engagement and support.  This type of care often requires significant paradigms shifts with technological and organizational transformation within health systems, which in turn are difficult to sustain under a wide range of financing models. Each of the five cases highlights significant obstacles to establishing successful diabetes management programs. Challenges include:

  1. Changing the care paradigm.  Effective diabetes programs require a shift to the care paradigm away from traditional volume-based systems to patient-focused systems that facilitate integrated team-based care with patients as active members of the care team. There is often reluctance to system changes from both patients and providers. For example, patients within ThedaCare in Wisconsin were hesitant to participate in the complex care program because of worries that it would require changing providers or cost extra money. In India, patients within SughaVazhvu Healthcare have relied heavily on traditional healers over physicians, so engaging patients to start seeking care from SughaVazhvu’s trained providers was similarly challenging. At the same time, providers may be reluctant to adopt a new team-based care delivery model that could change their work arrangements and incomes, and create new uncertainty.

Engaging patients to promote healthy behavior.  Diabetes outcomes are better with effective self-management, and therefore patients must be engaged in understanding proper self-care and making healthy behavior changes.  Patient engagement activities include support for patient self-efficacy and the adaptation of educational programs to the patient’s individual context, which generally includes demographics, nutritional and activity behaviors, and literacy levels. In India, SughaVazhvu Healthcare had patients who lacked understanding about the connection between nutrition and diabetes.  In Texas the Rio Grande Valley Accountable Care Organization serves a patient population with an average education level of 6th grade that requires an adaption of the education to individual needs. The wide range of education and health literacy levels means that patient education on proper self-care requires individualized care.

Implementing technical innovations for improved measurement. Many diabetes innovations incorporate technology for improved care delivery for both patients and providers, starting with an emphasis on the most critical data and patient engagement in producing and using it. For example, CASALUD in Mexico, Ribera Salud in Spain, and ThedaCare have online patient health portals that patients can access through their computer or mobile device. Implementing these systems effectively requires practical solutions for access to technology, technological literacy, and overcoming preference for in-person appointments. Similarly, health care providers must find practical solutions for implementing secure and inter-operable technology systems to store electronic health records (EHRs), connect with patients, identify patients, and measure performance.

Creating sustainable payment systems. Addressing these challenges to transforming care for diabetes requires shifting to a payment model that supports patient-focused care transformation.  To varying degrees, providers in each of the case studies have moved from a fee-for-service or public-budget environment, which may not support coordinated care and other low-cost care innovations, to one in which payments occur at the person level and are tied to better results and lower overall costs.

Policy Solutions for Patient-Centered Care: Upcoming event To learn more about how these innovative programs are addressing common challenges in reforming care and implementing new payment models, we invite you to attend our event on April 7th entitled, Disruptive Innovation in Diabetes Care from Around the World: Lessons for Health Reform in the U.S. The event will be hosted by the Richard Merkin Initiative for Payment Reform and Clinical Leadership.