For services on or after may 5, 2016, Palmetto will require only two HbA1c tests annually for patients with diabetes mellitus type 2 (DMII) who have "two [quarterly] consecutive HbA1c results meeting the treatment goals specified in the plan of care."
But Palmetto's updated local coverage determination (LCD) still requires quarterly HbA1c values in home health records of patients “whose therapy has changed (think sliding scale, dose change, or insulin-type change) or who are not meeting glycemic goals (think HbA1c targets out of reach for the patient).” Palmetto based its decision on claims data and the increased risk of emergency department (ED) encounters and acute inpatient admissions related to hypoglycemia" in such patients. The 2016 American Diabetes Association (ADA) standards support Palmetto's stand.
Sharing the 2016 ADA standards for elderly, chronically ill DM II patients may help physicians who resist HbA1c testing on Palmetto-dictated schedules.
Think of the potential for decreased quarterly HbA1c levels fueled by home health nurses who help patients adhere to treatment and therapy changes (think increased visit frequency for follow up). And what if home health nurses focused more on working with physicians, patients, and families to set and reach achievable goals for glycemic control? Is it possible that we home health nurses, wanting only the best for our patients, of course, sometimes advocate treating DM II too aggressively in elderly, chronically ill, DM II patients?
Elderly people probably should not go on tight control. Hypoglycemia can cause strokes and heart attacks in older people. Also, the major goal of tight control is to prevent complications many years later. Tight control is most worthwhile for healthy people who can expect to live at least 10 more years.
Some people who already have complications should not be on tight control. For example, people with end-stage kidney disease or severe vision loss probably should not try it. Their complications are probably too far along to be helped. Some people who have coronary artery disease or vascular disease should not try tight control.
People who have hypoglycemia unawareness probably should not go on tight control.
- See more at: http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/tight-diabetes-control.html#sthash.hDS1JONH.dpufThe LCD states Palmetto's goal as helping elderly patients with DM II avoid hypoglycemia-related emergency department visits and hospitalizations, seen as "potentially preventable adverse drug events." Palmetto states that elderly patients with multiple illnesses may avoid such hypoglycemic events by loosening HbA1c target goals to around < 8.5.
The ADA agrees that tight blood glucose control is not indicated for elderly people, especially those with coronary artery disease, vascular disease, "hypoglycemia unawareness" (think dementia), and with complications from diabetes.
Elderly people probably should not go on tight control. Hypoglycemia can cause strokes and heart attacks in older people. Also, the major goal of tight control is to prevent complications many years later. Tight control is most worthwhile for healthy people who can expect to live at least 10 more years.
Some people who already have complications should not be on tight control. For example, people with end-stage kidney disease or severe vision loss probably should not try it. Their complications are probably too far along to be helped. Some people who have coronary artery disease or vascular disease should not try tight control.
People who have hypoglycemia unawareness probably should not go on tight control.
- See more at: http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/tight-diabetes-control.html#sthash.hDS1JONH.dpufElderly people probably should not go on tight control. Hypoglycemia can cause strokes and heart attacks in older people. Also, the major goal of tight control is to prevent complications many years later. Tight control is most worthwhile for healthy people who can expect to live at least 10 more years.
Some people who already have complications should not be on tight control. For example, people with end-stage kidney disease or severe vision loss probably should not try it. Their complications are probably too far along to be helped. Some people who have coronary artery disease or vascular disease should not try tight control.
People who have hypoglycemia unawareness probably should not go on tight control.
- See more at: http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/tight-diabetes-control.html#sthash.hDS1JONH.dpufthatelderly people, especially those coronary artery or vascular disease, or those I assume that all home-health nurses seek, receive, and carry orders in response to patient needs rather than to fit into the nurses' schedules. Sadly, I've seen many patient records that don't support my assumption.Consider the potential here. Home health can show Medicare (and Congress, and private insurers . . .) that DM II patients with home health services avoid hypoglycemic episodes that land them in the ER or the hospital. Better quality of life for beneficiaries, and cost savings for Medicare. Voilà!
"This policy establishes the expectation that for those Medicare beneficiaries requiring medications to achieve long-term control of glucose levels, Metformin shall be considered first-line therapy unless there is a specific contraindication to its use," The LCD says. "Likewise Medicare beneficiaries who despite being maintained on daily insulin regimens are poorly controlled should be considered for treatment with Metformin."
Palmetto stops just short of stating it won't cover home health visits for insulin injections (Did you read it between the lines, too?) when the nurse-injected insulin doesn't prevent treatment changes and/or doesn't result in model HbA1c values.
Hold it. Home health is supposed to document treatment changes to show medical necessity for home health services, right? What's different here?
Chapter 7 in the Medicare Benefit Policy Manually consistently states that ongoing care is not reasonable or medically necessary if it doesn't achieve the goals for treatment in the plan of care. And, of course, the care must qualify as a skilled service under the Medicare home health benefit.
Rather than showing that the DM II home health patient's blood glucose is tightly controlled with ongoing treatment changes and repeated proof of instability, documentation of nursing visits to administer insulin to a patient with DM II should show that the treatment is effectively meeting reasonable, achievable, patient-specific goals. If the patient's insulin injections do this, Palmetto requires HbA1c tests only twice a year,
Hmmm. It's worth some thought.