State Plan for Diabetes
and Obesity Treatment
As Required by
Texas Health and Safety Code,
Section 103.013
Texas Diabetes Council
November 2021
i
Table of Contents
Executive Summary ............................................................................... 2
1. Introduction ...................................................................................... 3
2. Background ....................................................................................... 4
3. 2019 Texas Diabetes Action Plan Update ........................................... 6
Diabetes Self-Management Education and Support (DSMES) Enrollment ...... 6
Evidence-Based Prevention Program Engagement .................................... 8
Address Obesity and Prediabetes in School-Aged Children ......................... 9
4. 2021 Texas Diabetes Action Plan ..................................................... 11
Increasing Transparency in Insulin and Drug Pricing for Diabetes Treatments
................................................................................................. 11
Reducing Therapeutic Interference in Hospital Settings ........................... 13
Making Telehealth and Telemedicine Permanent ..................................... 14
Decreasing Identified Health Disparities for All Persons with Diabetes and
Obesity ....................................................................................... 17
Expanding Use of Automated Diabetes Technologies ............................... 19
5. Conclusion ....................................................................................... 21
List of Acronyms .................................................................................. 22
Appendix A. Texas Diabetes Council Membership................................ A-1
2
Executive Summary
Texas Health and Safety Code, Chapter 103, established the Texas Diabetes Council
(TDC). Section 103.013 requires TDC to develop and implement a state plan for
diabetes treatment, education, and training.
In conjunction with developing the state plan, the TDC also assesses existing state
programs for the prevention and treatment of diabetes, in accordance with Section
103.0131. The assessment includes a review of state agency programs that provide
diabetes-related services and can be found at dshs.texas.gov/legislative/Reports-
2021.aspx.
This plan is based on reviews and discussions of diabetes prevention and self-
management, cost-savings studies, and evidence-based diabetes research studies.
TDC members’ professional experiences span decades and include expertise in the
treatment of diabetes, diabetes education and training, nutrition education, and
public health policy. TDC meetings serve as opportunities to review and discuss
topics, which assist in the identification of these priorities as outlined in the Texas
Diabetes Action Plan:
● Increasing transparency in insulin and drug pricing for diabetes treatments to
ensure medications for persons with diabetes are available and affordable.
● Reducing therapeutic interference in hospital settings from formularies
prohibiting patients access to the medications their treating physicians
prescribe.
● Making telehealth and telemedicine permanent to increase access to
healthcare and improve patient outcomes.
● Decreasing identified health disparities for all persons with diabetes and
obesity to provide equal access to quality healthcare, education, medication,
and equipment regardless of socioeconomic factors.
● Expanding use of automated diabetes technologies for increased access to
and utilization of continuous sugar monitoring systems and other diabetes-
related technological advancements to improve self-management outcomes
for the health and well-being of people with diabetes.
3
1. Introduction
The Texas Diabetes Council (TDC) was established by the Legislature per Texas
Health and Safety Code, Chapter 103. It is composed of 11 members appointed by
the Governor, as well as nonvoting members from the Texas Department of State
Health Services (DSHS), the Texas Health and Human Services Commission
(HHSC), the Texas Workforce Commission Vocational Rehabilitation Division, the
Employee Retirement System of Texas (ERS), and the Teacher Retirement System
of Texas.
Texas Health and Safety Code, Section 103.013, requires the TDC to develop and
implement a state plan for diabetes treatment, education, and training. The TDC
submits the state plan to the state agency designated as the state health planning
and development agency by November 1 of each odd-numbered year.
Section 103.013 allows the state plan to ensure the following:
● Individual and family needs are assessed statewide and all available
resources are coordinated to meet those needs; and
● Healthcare provider needs are assessed statewide and strategies are
developed to meet those needs.
Health and Safety Code, Section 103.013(b-1), allows the TDC to include in the
state plan provisions to address obesity treatment, education, and training related
to:
● Obesity-dependent diabetes; and
● The health impacts of obesity on a person with diabetes.
4
2. Background
The prevalence of diabetes in Texas has nearly doubled over the past decade –
from 6.2 percent to 12.2 percent.
1
Today, more than 2.5 million (12.2 percent) of
adult Texans have been diagnosed with diabetes, and nearly 2.2. million (10.1
percent) of adult Texans have prediabetes.
2
This condition increases their risk for
heart disease and stroke.
3
According to the Texas Demographic Center, the number of persons with diabetes
is projected to be nearly 8 million people by 2040, while the prevalence may
increase to 23.8 percent.
4
Texas is among 21 states collectively responsible for over
40 percent of the national cost of diabetes.
5
The annual financial toll on Texas due
to diabetes is $26 billion dollars, including $18.9 billion in direct medical costs and
$6.7 billion in indirect costs.
6
The price of insulin has risen steeply, resulting in
patients rationing this lifesaving medication.
7
Between 2009 and 2019, insulin
1
Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System
Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention, 2019.
2
Texas Department of State Health Services, Prevalence of Diagnosed Diabetes Among Adults by
Demographic Characteristics, Risk Factor/Comorbid Conditions, and Place of Residence, Texas, 2019.
3
Centers for Disease Control and Prevention. Diabetes and Prediabetes, 2019.
https://www.cdc.gov/chronicdisease/resources/publications/factsheets/diabetes-prediabetes.htm.
4
Texas Demographic Center. Summary Report on Diabetes Projections in Texas, 2007 to 2040.
http://demographics.texas.gov/Resources/Publications/2008/2008_SummaryReportDiabetes.pdf.
5
Economic Costs Attributable to Diabetes in Each U.S. State. Diabetes Care 2018; 41:2526-2534.
https://care.diabetesjournals.org/content/diacare/41/12/2526.full.pdf.
6
American Diabetes Association (2018). The Burden of Diabetes in Texas.
http://main.diabetes.org/dorg/docs/state-fact-sheets/ADV_2020_State_Fact_sheets_TX.pdf.
7
Prasad R. The human cost of insulin in America. BBC website. https://www.bbc.com/news/world-us-
canada-47491964. Published March 14, 2019. Accessed July 1, 2021.
5
prices rose significantly, and the cost of other important medications for persons
with diabetes are unaffordable.
8
,
9
,
10
Although some diabetes-related complications have decreased since the 10-year
Diabetes Control and Complications Trial was completed in 1993, one notable
exception is the incidence of lower extremity amputations, which has increased
among working-age adults since 2010.
11
,
12
In 2018, there were approximately
14,000 diabetes-related nontraumatic lower limb amputations in Texas at a cost of
more than $1.6 million.
13
The 5-year survival rate for people with diabetic foot
ulcers and major lower limb amputations is over 30 percent and 55 percent,
respectively.
14
As a result, these diabetes-related complications are often more fatal
than many types of cancer.
14,
15
Complications increase healthcare spending, reduce
productivity, and impact the physical, emotional, and financial well-being of persons
with diabetes and their families.
8
Hua X., Carvalho N., Tew M., Huang E.S., Herman, W.H., Clarke P. (2016). Expenditures and prices
of antihyperglycemic medications in the United States: 2002-2013. Journal of the American Medical
Association, 315:1400–1402.
9
Cefalu, W.T., Dawes, D.E., Gavlak, G., Goldman, D., Herman, W.H., Van Nuys, K., Powers, A.C.,
Taylor, S.I., and Yatvin, A.L. on behalf of the Insulin Access and Affordability Working Group. (2018).
Insulin Access and Affordability Working Group: Conclusions and Recommendations. Diabetes Care,
2018 June; 41 (6): 1299-1311.
10
Mayo Clinic Proceedings. January 2020;95(1):22-28.
https://doi.org/10.1016/j.mayocp.2019.11.013.
11
Gregg, E.W., Hora, I., and Benoit, S.R. (2019). Resurgence in diabetes-related complications.
Journal of the American Medical Association. 321(19):1867–1868. doi:10.1001/jama.2019.3471.
12
Gregg EW, Li Y,Wang J, et al. Changes in diabetes-related complications in the United States, 1990-
2010. N Engl J Med. 2014;370(16):1514-1523.
13
Texas Department of State Health Services. Hospital Discharge Rates for Overall Diabetes, Type 1
Diabetes, Type 2 Diabetes, and Diabetes-Related Nontraumatic Lower Extremity Amputations by
Demographics, Public Health Region, County, Median Length of Stay and Total
Charges by Primary Payer, Texas 2018.
14
Armstrong, D.G., Swerdlow, M.A., Armstrong, A.A. et al. Five-year mortality and direct costs of care
for people with diabetic foot complications are comparable to cancer. J Foot Ankle Res 13, 16 (2020).
https://doi.org/10.1186/s13047-020-00383-2.
15
Cancer Facts & Figures 2019. https://www.cancer.org/content/dam/cancer-org/research/cancer-
facts-and-statistics/annual-cancer-facts-and-figures/2019/cancer-facts-and-figures-2019.pdf.
6
3. 2019 Texas Diabetes Action Plan Update
In addition to 16 members, the Texas Diabetes Council (TDC) has two workgroups:
the Advocacy and Outreach Workgroup (AOW) and the Healthcare Professionals and
Outcomes Workgroup (HPOW).
The AOW brings together diabetes stakeholders to develop recommendations for
issues affecting persons with diabetes. Stakeholders include the American Diabetes
Association (ADA), the Association of Diabetes Care and Education Specialists
(ADCES), the Juvenile Diabetes Research Foundation, healthcare systems, health
plans, and other interested parties.
The HPOW assembles leading Texas endocrinologists, nurses, dietitians, diabetes
educators, and other diabetes experts to review the minimum practice standards
data from state agency programs, health systems, and special studies that can be
used to assess the effectiveness of diabetes management in Texas. Both
workgroups assist TDC members (Appendix A) in executing legislatively required
duties, developing the state plan for diabetes and obesity treatment and education,
and supporting TDC initiatives.
Over the biennium, collaborative statewide efforts have helped to make progress
towards achieving the following 2019 State Plan for Diabetes and Obesity
Treatment priorities:
● Diabetes Self-Management Education and Support Enrollment;
● Evidence-Based Prevention Program Engagement; and
● Address Obesity and Prediabetes in School Aged Children.
Diabetes Self-Management Education and Support
(DSMES) Enrollment
The TDC prioritized decreasing the DSMES enrollment gap, with the goal of
reducing diabetes-related hospital admissions and readmissions. In 2019 and 2020,
The TDC administered surveys to gain an understanding of how Managed Care
Organizations (MCOs) provide diabetes education to Medicaid enrollees. The survey
was sent to one person in each of Texas’s 18 MCOs; 12 people completed the
survey. Based on the responses received from MCO program coordinators and
managers, it was noted that there remains a gap between the number of Medicaid
7
participants with diabetes and DSMES enrollment. Both Tables 1 & 2 show there is
a small percentage of MCO participants, living with type 1 and 2 diabetes mellitus,
who enrolled in and/or completed DSMES. A low percentage of Medicaid enrollees
with gestational diabetes mellitus enrolled in DSMES, but of those who enroll,
completion was 100 percent.
Table 1. How many adult patients (≥21 years) served by your MCO, with the
following health conditions, enrolled in and completed DSMES between January 1,
2019-December 31, 2019?
Number of adult
patients served by
MCOs
Type 1 diabetes mellitus
5,523
Type 2 diabetes mellitus
74,334
Gestational diabetes mellitus
11,039
Table 2. How many adolescent patients (<21 years) served by your MCO, with the
following health conditions, enrolled in and completed DSMES between January 1,
2019-December 31, 2019?
Number of
adolescent patients
served by MCOs
Type 1 diabetes mellitus
2,993
Type 2 diabetes mellitus
5,130
Gestational diabetes mellitus
695
Survey results gave insight on how MCOs provide diabetes education, and further
research indicated that the Texas Medicaid Provider Procedures Manual (TMPPM)
included language that may have contributed to gaps in DSMES enrollment. The
TDC provided a topic nomination to the Texas Health and Human Services
Commission (HHSC) regarding DSMES benefits, which was approved by HHSC
Governance for further medical benefit policy review.
8
TDC recommendations for consideration included the following:
1. Texas Medicaid Fee-for-Service (FFS) and MCOs provide DSMES services
following the current National Standards for DSMES, as published by the ADA
and the ADCES.
2. Texas Medicaid FFS and MCOs provide coverage of DSMES services to
Medicaid recipients diagnosed with diabetes (i.e., type 1, type 2 or
gestational diabetes).
a. Eligible recipients must receive up to 10 hours of DSMES during the first
12-month period after diagnosis and include:
i. One hour of individual DSMES, and
ii. Nine hours of group DSMES.
b. After the first 12-month period has ended, recipients must be eligible for
two hours of individual instruction on diabetes self-management per
calendar year.
c. To receive Medicaid reimbursement, a DSMES must meet the quality
standards of ADA or ADCES.
d. Texas Medicaid must utilize the services of an ADA-recognized or ADCES-
accredited DSMES provider.
e. FFS and MCOs must demonstrate use of Medicaid quality measures.
Evidence-Based Prevention Program Engagement
The TDC continues to prioritize evidence-based prevention program engagement to
provide potential cost-savings for employers, insurers, and government agencies.
Increasing availability and access to National Diabetes Prevention Program
(National DPP) services remains a priority for diabetes stakeholders, as evidenced
by the growth in the number of programs in Texas. The National DPP is an example
of a public-private partnership of community-based organizations, private insurers,
healthcare organizations, employers, and government agencies brought together to
establish evidence-based lifestyle change programs for people at high risk for type
2 diabetes. Over the biennium, the number of lifestyle change programs and sites
in Texas increased from approximately 50 to 75 programs.
The TDC continued to collaborate with the Employees Retirement System of Texas
(ERS) to assess the prevalence of prediabetes among the state employee
population, develop an economic analysis related to providing an evidence-based
prevention program, develop and implement a cost-effective type 2 diabetes
prevention program for state employees, and report to the Legislature and
Governor.
9
As a result, ERS began providing coverage for Real Appeal and Wondr (formerly
Naturally Slim), online wellness programs that support a reduction of type 2
diabetes risk factors through weight loss and mindful, healthy eating. In the 2019
State Plan for Diabetes and Obesity Treatment, the TDC recommended continued
implementation of these wellness programs to support a return on investment from
reduced state employee insurance claims for diabetes, obesity, and other chronic
co-morbid conditions. Both programs are offered to current and retired state
employees and dependents enrolled in HealthSelect, but not Medicare.
16
HealthSelect is the network-based, point-of-service plan administered by Blue Cross
and Blue Shield of Texas through ERS. According to the FY20 Texas Employees
Group Benefits Program Annual Report:
“ERS is actively working with the leadership of the 16 largest state agencies
and institutions to decrease the prevalence of major chronic conditions,
improve participants’ general quality of life, and reduce long-term health
costs for HealthSelect. Through collaboration and leader-led support, the
Texas Department of Public Safety and Texas Tech University System
improved participation rates in weight management programs and online
health assessments in FY20.”
17
Address Obesity and Prediabetes in School-Aged
Children
The 2019 State Plan for Diabetes and Obesity Treatment included partnership with
the Texas Education Agency (TEA) to review the Texas Essential Knowledge and
Skills (TEKS), the state standards for what students should know and be able to do.
To address the obesity and prediabetes crisis in Texas’ school-aged children, in
2019 the TDC partnered with TEA to ensure the revised health education and
physical education curriculum standards would provide learning objectives for
grades K-12. At that time, Texas ranked 14
th
in the nation for obesity, with 33
16
Blue Cross Blue Shield of Texas HealthSelect. Weight Management Programs.
https://healthselect.bcbstx.com/content/health-and-wellness-incentives/weight-management-
programs.
17
Employees Group Benefits Program Annual Report FY20. https://ers.texas.gov/about-ers/reports-
and-studies/reports-and-studies-on-ers-administered-benefit-programs/fy20-gbp-annual-report.pdf.
10
percent of the population being obese.
18
The status was even higher for high school
students: Texas ranked 5
th
with 18.6 percent of high school students having
obesity.
18
There is a strong correlation between obesity and type 2 diabetes.
The ad hoc TDC TEKS Curriculum Workgroup had the opportunity to provide
stakeholder feedback for both the Health Education and Physical Education TEKS
during the review process. The workgroup assisted with the development of an
advanced-level high school health education course, served as a content advisor,
and provided feedback in alignment with the TDC’s mission. These efforts were
instrumental in the review and adoption of the revised Health Education TEKS. This
is significant as these standards impact over 5 million students in Texas public
schools and had not been revised in over 20 years.
The recommended revisions aimed to provide students an opportunity to learn
about obesity and diabetes and their prevention, management, and potential
complications. Recommendations also sought to establish a physical education time
requirement for elementary and middle school students, since the TEKS previously
had no minimum time requirement. These standards were needed to reduce the
obesity epidemic among Texas youth. This is particularly pronounced among
Hispanic/Latino and African American children population.
19
The Texas State Board
of Education approved and adopted the revised TEKS in November 2020, and it will
be effective in August 2022.
In accordance with Texas Health and Safety Code, Chapter 103, and in consultation
with DSHS, resources were provided to TEA to educate and support students and
parents of students with diabetes. Resources include an overview of type 1 and
type 2 diabetes, safe-at-school state laws, and information for families, caregivers,
and school personnel on managing diabetes in academic settings. These resources
are available at dshs.texas.gov/txdiabetes/school and may be shared through
health clinics at public primary or secondary schools.
18
Robert Wood Johnson Foundation. The State of Obesity–Better Policies for a Healthier America.
State of Obesity https://www.stateofobesity.org. Accessed July 1, 2021.
19
Healthy Children, Healthy State: Child Obesity Crisis in Texas.
https://sph.uth.edu/research/centers/dell/resources/new/child+obesity+crisis+final.pdf. Accessed July
19, 2021.
11
4. 2021 Texas Diabetes Action Plan
The Texas Diabetes Council (TDC) developed a Texas Diabetes Action Plan that
consists of priorities for areas that build on past accomplishments and use current
national, state, and local efforts to improve diabetes education and management in
Texas. Work in the priority areas that follow is dependent on the Texas Legislature’s
continued funding and support of the Diabetes Prevention and Control Program at
the Texas Department of State Health Services (DSHS).
The following priorities will be discussed in this state plan:
● Increasing Transparency in Insulin and Drug Pricing for Diabetes Treatments;
● Reducing Therapeutic Interference in Hospital Settings;
● Making Telehealth a Permanent Benefit;
● Decreasing Identified Health Disparities for All Persons with Diabetes; and
● Expanding Use of Automated Diabetes Technologies.
Increasing Transparency in Insulin and Drug
Pricing for Diabetes Treatments
The price of insulin has tripled over the past decade, and continually climbing costs
are a key barrier to effective diabetes self-management.
20
Due to price increases,
insulin rationing, by taking smaller doses or skipping doses, has become common
and is detrimental to the health of persons with diabetes.
7
A study at the Yale
Diabetes Center found that between June and August 2017 one in four people
rationed insulin due to its cost, which contributed to poor blood sugar
management.
21
Insulin rationing, a dangerous practice that compromises the health and safety of
persons with diabetes, can increase the risk of hospitalization and complications
such as blindness, amputations, and death. For patients, rationing medication
20
Gordon, S., High cost has many diabetics cutting back on insulin. CBS News Web site.
https://www.cbsnews.com/news/high-cost-of-insulin-some-diabetics-cut-back. Published December 3,
2018. Accessed July 1, 2021.
21
Lipska KJ. Insulin Analogues for Type 2 Diabetes. JAMA. 2019;321(4):350–351.
doi:10.1001/jama.2018.21356.
12
erodes their health. For the state of Texas, there are increased medical costs
associated with hospital admissions/readmissions and health complications.
In commentary associated with the Yale Diabetes Center study, the Kaiser Health
News Editor-in-Chief, Dr. Elizabeth Rosenthal, noted:
“Thanks to tight sugar control and more precise insulin dosing, researchers
estimated in 2012 that children with diabetes born between 1965 and 1980
were living 15 years longer than those born between 1950 and 1965.”
22
For those who ration insulin because of its cost, that 15-year gain may be
diminished.
In the 2019 State Plan for Diabetes and Obesity Treatment, the TDC recommended
there be more transparency in insulin and drug pricing for diabetes treatments and
capping insulin co-pays at $100 per month to expand affordability. In 2021, the
87th Texas Legislature passed Senate Bill (S.B.) 827, capping insulin co-pays at
$25 per month for each prescription for individuals insured through state-regulated
health benefit plans.
House Bill (H.B.) 18, passed during the 87th legislative session, establishes the
development of a prescription drug savings program for Texans without health
benefit plan coverage. This program will allow uninsured Texans to purchase
prescription drugs, including insulin, at a reduced, post-rebate price. H.B. 18 also
requires the Texas Health and Human Services Commission (HHSC) to conduct a
study on the implementation of the program and report the results of the study by
February 14, 2025. This legislation complements H.B. 2536, passed during the 86th
legislative session, which required pharmacy benefit managers and health insurers
to annually submit reports related to prescription drug cost transparency to the
Texas Department of Insurance.
Prior to the 87th legislative session, Texas law only allowed for a three-day
emergency refill of insulin and insulin-related equipment and supplies. This
limitation could cause acute health complications or potentially be fatal for people
who depend on insulin to manage diabetes. H.B. 1935 was passed during the 87th
legislative session to help alleviate this issue, allowing pharmacists to dispense a
30-day emergency supply of insulin and insulin-related equipment and supplies if
22
Rosenthal E. When high prices mean needless death. JAMA Intern Med. 2019;179(2):114-115. doi:
10.1001/jamainternmed.2018.5007.
13
specific criteria are met. Health benefit plans must also provide coverage for
emergency refills of equipment or supplies in the same manner as nonemergency
refills.
All above mentioned bills took effect on September 1, 2021.
Texas Diabetes Council Recommendations
To build on the 2021 legislation and ensure progress toward insulin pricing
transparency, TDC recommends the following be considered by the 88th Texas
Legislature in 2023:
● Require insulin manufacturers to provide to HHSC details on the factors
leading to price increases and the portion of the price increase related to
those factors; and
● Require further detail in explaining insulin price increases, including
information on the drug’s acquisition by the manufacturer and specific costs
attributed to the drug.
Reducing Therapeutic Interference in Hospital
Settings
In Texas, the physician licensed to practice medicine is the only professional that
can make therapeutic decisions and prescribe medications independently. Allied
health professionals, such as physician’s assistants and nurse practitioners, make
therapeutic decisions and prescribe medications in consultation with a licensed
physician.
Currently in Texas hospitals, medication formulary decisions can include non-clinical
administrators, formulary committees, non-physicians, and/or physicians that are
not licensed to practice medicine in Texas. Local hospital formulary committees,
often chaired by physicians not involved in direct patient care, are required to
approve formulary changes based on corporate, not medical, decisions. These
decisions may limit or prevent a licensed physician from prescribing medications
with a significant therapeutic benefit and the potential to reduce hospital
admissions/readmissions or mortality.
There are medications to treat diabetes that aid in reducing morbidity, mortality,
and hospital admissions/readmissions. These medications are not always
administered to patients in an effort by the hospital to reduce costs. However, this
14
practice does not reduce long-term costs to the health care system or improve
patients’ quality of life. Studies have shown that starting a medication while in the
hospital may increase adherence after discharge, improving long-term efficacy for
the patient and healthcare system.
23
,
24
,
25
Therefore, physicians should be allowed to
initiate therapy that provides a maximum benefit to patients without interference.
Texas Diabetes Council Recommendations
To reduce therapeutic interference in hospital settings, increase physicians’ ability
to treat patients and improve health outcomes, the TDC recommends the following
be considered by the 88th Texas Legislature in 2023:
● Explore legislation to minimize hospital formularies from restricting access to
medications with the most therapeutic benefit to patients and lessen
interference of the treatment protocol outlined by the prescribing physician.
Making Telehealth and Telemedicine Permanent
The use of both telehealth and telemedicine increased during 2020 due to the
COVID-19 pandemic, as healthcare abruptly shifted from providing in-person care
to online platforms/services or via telephone. Telehealth is the use of electronic and
telecommunication technologies to provide care and services at-a-distance (e.g.,
remote non-clinical services such as participating in a DSMES class). Telemedicine
is the practice of medicine using technology to deliver care at a distance (e.g.,
remote clinical services such as a doctor’s appointment). Healthcare providers rely
on patient data to make treatment decisions and recommendations for persons
living with diabetes. Due to advances in technology, devices such as blood sugar
meters, insulin pumps, and continuous sugar monitoring systems enable patients to
upload data for providers to review. For people living with diabetes, access to
telehealth and telemedicine is ideal.
23
Medication Adherence: WHO Cares? Mayo Clin Proc. 2011 Apr; 86(4): 304–314.
doi:10.4065/mcp.2010.0575.
24
In-hospital initiation of lipid-lowering therapy after coronary intervention as a predictor of long-term
utilization: a propensity analysis. Aronow HD, Novaro GM, Lauer MS, Brennan DM, Lincoff AM, Topol
EJ, Kereiakes DJ, Nissen SE. Arch Intern Med. 2003 Nov 24; 163(21):2576-82.
25
In-hospital initiation of statins: taking advantage of the 'teachable moment'. Fonarow GC. Cleve Clin
J Med. 2003 Jun; 70(6):502, 504-6.
15
Research has indicated there are better outcomes among individuals living with
diabetes who access the health system through telemedicine. According to a study
published in 2019, researchers conducted a meta-analysis of 6,170 patients’ data
from 42 randomized controlled trials to examine the clinical effectiveness of
telemedicine compared to traditional in-person diabetes management strategies.
26
The study populations included data from 12 studies focused on type 1 diabetes, 21
studies focused on type 2 diabetes, and 9 studies that involved both type 1 and
type 2 diabetes.
26
The results demonstrated a significantly greater average
reduction in hemoglobin A1c (HbA1c) in the telemedicine groups compared to
traditional in-person care.
26
This was especially true in trials lasting longer than six
months and in patients with type 2 diabetes.
26
Greater benefits were also observed
in older study participants between the ages of 41-50 or older than 50 years of age
when compared with younger patients.
26
Telehealth can increase access to healthcare, which is especially important for
people living with chronic conditions like diabetes. Diabetes requires ongoing self-
care to manage blood sugar and reduce the potential for complications. For
individuals and families with limited resources, self-care may become increasingly
challenging as basic needs (e.g., food, housing, etc.) outweigh chronic disease
management and routine visits with their healthcare provider.
27
Telehealth is an
effective strategy for providing medical care, improving patient adherence to
treatment, and increasing participation and retention in diabetes education
programs in underserved and rural populations.
28
Telehealth also offers a method
for individualizing and adapting interventions and providing ongoing support,
fundamental elements of the National Standards for Diabetes Self-Management
Education and Support and the Centers for Disease Control Diabetes Prevention-led
National Diabetes Prevention Program. Enhancing patient access and outcomes can
contribute to fewer hospital admissions and readmissions, lower likelihood of
development or worsening of comorbid conditions, and/or reduction of treatments
26
Tchero, H., Kangambega, P., Briatte, C. et al. Clinical Effectiveness of Telemedicine in Diabetes
Mellitus: A Meta-Analysis of 42 Randomized Controlled Trials. Telemedicine and e-Health 569-585
(July 2019). doi: 10.1089/tmj.2018.0128.
27
Ju, H. Using telehealth for diabetes self-management in underserved populations. The Nurse
Practitioner, 2020 November; 45 (11): 26-33. doi: 10.1097/01.NPR.0000718492.44183.87
28
Telehealth in rural
communities. www.cdc.gov/chronicdisease/resources/publications/factsheets/telehealth-in-rural-
communities.htm.
16
needed for costly health complications. Accordingly, diabetes-related healthcare
expenditures would decrease.
29
During the COVID-19 pandemic, under an emergency Texas Department of
Insurance rule, state-regulated health insurers and health maintenance
organizations were required to:
● Pay in-network health professionals at least the same rate for telemedicine
as in-person visits, including covered mental health services;
● Cover telemedicine services using any platform permitted by state law; and
● Not require more documentation for telemedicine than they require for in-
person services.
An emergency rule (28 Texas Administrative Code, Section 35.1) was issued to
suspend a state law limiting insurance coverage for medical services or
consultations by phone.
30
By suspending the law, insurers were required to pay for
covered visits or consultations provided over the phone and telemedicine. In June
2021, two House Bills were passed, H.B. 4 and H.B. 5, that may impact access to
and provision of health services delivered electronically. H.B. 4 is related to the
provision and delivery of certain health care services in Texas, including services
under Medicaid and other public benefits programs, using telecommunications or
information technology and reimbursement for some of those services. H.B. 5 is
related to the expansion of broadband Internet services to certain areas.
Additionally, the Texas Medical Board issued guidance to allow physicians and other
healthcare professionals to use phone consultations to establish a provider-patient
relationship. Before these changes, telemedicine could be provided only after the
provider-patient relationship had been established during an in-person visit.
Texas Diabetes Council Recommendations
People with diabetes and risk factors for type 2 diabetes (e.g., prediabetes),
especially in rural and underserved areas, would benefit from making the
temporary expansion of telehealth and telemedicine permanent because of the risk
29
Halpren-Ruder D. Telehealth: a primer. 2018. www.psqh.com/analysis/telehealth-a-primer.
30
Texas Administrative Code, Title 28, Chapter 35, Subchapter A. COVID-19 Emergency Rules.
https://www.tdi.texas.gov/rules/2020/documents/20206287.pdf. Accessed August 5, 2021.
17
of COVID-19 infection. Therefore, the TDC recommends the following be considered
by the 88th Texas Legislature in 2023:
● Enact law to permanently allow the use of and require full reimbursement for
telehealth and telemedicine services; and
● Allow healthcare professionals to use phone consultations to establish the
provider-patient relationship, per the Texas Medical Board’s guidance in
response to the COVID-19 pandemic.
Decreasing Identified Health Disparities for All
Persons with Diabetes and Obesity
Managing chronic conditions such as diabetes and obesity can be challenging, even
under ideal circumstances. During the emergence of the COVID-19 pandemic, the
concerns about health inequity, healthcare professionals’ competency in diversity,
and inclusion in healthcare were brought to the forefront. In 2019, Texas was
ranked 37
th
on the Opportunity Index, an annual report on community wellbeing
using economic, educational, health, and community data to look at disparities,
discrimination, and inequities.
31
For Texans living with chronic co-morbid conditions, health insurance, access to
healthy and affordable food, transportation to/from medical appointments, and
access to telehealth/telemedicine are just a few needs for managing their health.
For health systems to assist with tackling these needs, providers require standards
for addressing health equity, including training, inclusive health promotion, and
adequate care coordination. Training and support to address providers’ attitudes
and biases, payment/reimbursement for services, and referrals for ancillary patient
services and support are also necessary.
Access to medical, pharmaceutical, and technological advances in diabetes and
obesity care can improve the health and quality of life for individuals living with
these conditions. Improved access and health may help to prevent complications,
hospital admissions and readmission, and frequent use of emergency room or other
high cost healthcare services.
31
Opportunity Index: How Opportunity Measures Up in Your Community. State Rankings—Texas.
https://opportunityindex.org/detail/48/. Accessed July 1, 2021.
18
Texas needs a framework for implementation, integration, and success to address
health inequities. This includes demonstration of the benefits, strategies and
considerations for inclusive diabetes and obesity services with regards to social
determinants of health (e.g., education, income, place of residence). Furthermore,
in accordance with the ADA’s Health Equity Bill of Rights, persons living with
diabetes, prediabetes, or type 2 diabetes risk factors have the right to:
1. Access insulin and other drugs affordably;
2. Healthy food;
3. Insurance that covers diabetes management and future cures;
4. Not face stigma or discrimination;
5. Avoid preventable amputations;
6. Participate in clinical trials without fear;
7. Stop prediabetes from becoming diabetes;
8. A built environment that does not raise the risk of getting diabetes;
9. The latest medical advances; and
10.Have [their] voice heard.
32
Texas Diabetes Council Recommendations
A greater emphasis on understanding the impact of social determinants of health on
population health is needed to lessen the disparities experienced by vulnerable
communities. To address this problem, ADA recommends training researchers on
social determinants of health and their influence on diabetes prevention and
treatment.
33
Training priorities should include interdisciplinary science, multisector
collaboration research approaches, and methods to advance the root cause
research on social determinants of health.
33
In support of this recommendation, a
social determinants of health framework should guide the inclusion and diversity
training of the Texas healthcare workforce. This will strengthen the delivery of
culturally competent diabetes care and advance health equity.
To contribute to the development of the framework’s foundation for decreasing
health disparities for all persons with diabetes and obesity, the TDC will work on
these recommendations over the next biennium:
32
American Diabetes Association (2020). Health Equity Bill of Rights.
https://www.diabetes.org/sites/default/files/2020-08/Health%20Equity%20Bill_2nd_v2.pdf.
33
Hills-Briggs F., Adler N.E., Berkowitz S.A., Chin M.H., Gary-Webb T.L., Navas-Acien A., et al. Social
Determinants of Health and Diabetes: A Scientific Review. Diabetes Care. 2021; 44: 258-279.
19
● Collaborate with DSHS Grand Rounds to provide health equity training on
stigma, bias, amplifying voices and other relevant topics;
● Share health equity education opportunities through the DSHS Diabetes
Prevention and Control Program’s Diabetes News You Can Use quarterly
electronic newsletter;
● Conduct a systematic review of access to medications, healthy and affordable
food, and technology to manage diabetes and/or obesity among underserved
populations; and
● Identify and report in the 2023 State Plan for Diabetes and Obesity
Treatment constructed societal barriers to diabetes and obesity self-
management.
Expanding Use of Automated Diabetes Technologies
An evidence-based goal of diabetes self-management is attaining and sustaining
near normal blood sugar levels every day. Use of self-monitoring of blood sugar
technologies (SMBG) has moved patients closer to that goal over the last several
decades. Now, continuous sugar monitoring systems (CGMS) are expanding and
affording flexibility in SMBG for a growing number of Texans of all ages living with
diabetes. CGMS collects blood sugar data through a self-applied, removable sensor
inserted under the skin and transmits the reading to an insulin pump, smartphone,
or other CGMS-compatible device every five minutes. This empowers the person
with diabetes (or their caregiver) with the ability to make self-care decisions based
on real-time data trends, instead of “snapshots” of single points in time. Likewise,
CGMS allows providers more data to make therapeutic decisions and assist patients
with achieving improved clinical and quality of life outcomes.
CGMS data has created the clinical goal of “time in range.” Time in range refers to
the duration blood sugar is maintained between preset values (e.g., 70-180
mg/dL). An international consensus group has set at least 70 percent of the day or
greater as the preferred time in range for persons with diabetes.
34
Compared to the
hemoglobin A1c measurement, time in range is considered a superior reflection of
diabetes self-management outcomes in persons with diabetes using CGMS.
35
34
Battelino, Tadej, et al. Clinical targets for continuous sugar monitoring data interpretation:
recommendations from the international consensus on time in range. Diabetes Care 42.8 (2019):
1593-1603.
35
Clinical Diabetes. 2018 Apr; 36(2): 112–119. doi:10.2337/cd17-0094.
20
Over 20 years ago, Texas Medicaid approved the use of insulin pump devices for
Medicaid beneficiaries requiring insulin therapy to manage diabetes. Now, insulin
pumps are enabled with data from a companion CGMS device, or integrated into
the pump, to provide what is known as a “hybrid closed loop system.” The hybrid
closed loop system automatically adjusts subcutaneous insulin delivery based CGMS
values to assist patients, properly trained on the technology, achieve time in
range.
36
In 2019, Texas Medicaid approved use of certain CGMS devices for its
beneficiaries who meet specific criteria. This expansion acknowledged an ongoing
paradigm shift where real-time CGMS data is preferred over SMBG, which is based
on 1970’s era technology. However, all persons with diabetes still do not have
access to these advancements in care because of insurance constraints.
Texas Diabetes Council Recommendations
Since insulin pumps and some CGMS are approved for use by Texas Medicaid
beneficiaries, there should be progression to support the use of the hybrid closed
loop system for Texans with diabetes treated with insulin. As the “full closed loop”
is introduced, which aims to achieve even greater blood sugar management and
less fluctuations, this technology should also be supported. These technologies are
quickly becoming the standard of care for diabetes treatment, improving quality of
life and reducing long-term complications. Therefore, the TDC recommends the
following be considered by the HHS Texas Medicaid Program:
● Facilitate access to Federal Drug Administration-approved hybrid closed loop
insulin delivery systems, which incorporate continuous sugar monitoring
technology;
● Streamline the pre-authorization process to reduce approval time; and
● Encourage the establishment of a “best practices” model for training patients
on the proper use of hybrid closed loop systems and include curriculum-
based instruction in-person and via telehealth.
36
Bergenstal, Richard M., et al. Safety of a hybrid closed-loop insulin delivery system in patients with
type 1 diabetes. JAMA 316.13 (2016): 1407-1408.
21
5. Conclusion
Due to the projected increase in diabetes prevalence in Texas by 2040, there is a
concern that healthcare costs resulting from complications of poorly managed
diabetes and prescription costs will continue to inhibit affordability and
sustainability of the healthcare delivery system. This poses a simultaneous threat at
multiple levels: fiscally for the Legislature and Texas taxpayers, as well as to the
health and quality of life for all Texans.
TDC is committed to identifying strategies and working with partners to reduce
healthcare expenditures, improve delivery of evidence-based, cost effective
interventions, and increase access to preventative and therapeutic care to advance
population health in Texas.
22
List of Acronyms
Acronym
Full Name
ADA
American Diabetes Association
ADCES
Association of Diabetes Care and Education Specialists
AOW
Advocacy and Outreach Workgroup
CGMS
Continuous Sugar Monitoring System
DSHS
Texas Department of State Health Services
DSMES
Diabetes Self-Management Education and Support
ERS
Employee Retirement Systems of Texas
HHS
Texas Health and Human Services
HHSC
Texas Health and Human Services Commission
HPOW
Healthcare Professionals and Outcomes Workgroup
MCO
Managed Care Organization
National DPP
National Diabetes Prevention Program
TDC
Texas Diabetes Council
TEA
Texas Education Agency
TEKS
Texas Essential Knowledge and Skills
A-1
Appendix A. Texas Diabetes Council Membership
Member
Position Held
Expertise
Governor Appointed Representatives
Feyi Obamehinti, Ed.D.
Chair, General Public
Member
Diabetes Advocate
Stephen Ponder, MD,
FAAP, CDCES
Vice Chair, Public Health
Policy Member
Pediatric Endocrinologist,
Certified Diabetes Care
and Education Specialist
Aida “Letty” Moreno-
Brown, RD, LD
General Public Member
Diabetes Advocate
Ardis A. Reed, MPH, RD,
LD, CDCES
Registered and Licensed
Dietician Member
Registered and Licensed
Dietician, Certified
Diabetes Care and
Education Specialist
Christine Wicke, Pharm.D
Consumer Member
Pharmacist
Dirrell Jones, JD
General Public Member
Lawyer, Diabetes
Advocate
Felicia Fruia-Edge
Consumer Member
Diabetes Advocate
Gary Francis, MD, Ph.D
Physician Member
Pediatric Endocrinologist
Jason Michael Ryan, JD
Consumer Member
Lawyer, Diabetes
Advocate
Maryanne Strobel, RN,
MSN, CDCES
Registered Nurse
Member
Certified Diabetes Care
and Education Specialist
Ninfa Pena-Purcell, PhD,
MCHES
General Public Member
Professor, Master Certified
Health Education
Specialist
A-2
State Agency Representatives
Averi Mullins
State Agency Rep. (non-
voting member)
Teacher Retirement
System of Texas
Diana Kongevick
State Agency Rep. (non-
voting member)
Employees Retirement
System of Texas
Kelly Fegan-Bohm, MD,
MPH, MA
State Agency Rep. (non-
voting member)
Texas Department of
State Health Services
Lisa Golden, MAEdHD,
CRC, CDCES
State Agency Rep. (non-
voting member)
Texas Workforce
Commission Vocational
Rehabilitation
Mitchel Abramsky, MD,
MPH
State Agency Rep. (non-
voting member)
Texas Health and Human
Services Commission