November is National Diabetes Month, a time to bring greater attention to diabetes and the health problems it can cause. For health insurance payers, the observance also highlights a substantial provider network challenge.
Diabetes requires ongoing care rather than a single episode of treatment. Members typically rely on primary care physicians, specialists, pharmacies, and other health care professionals over the course of many years. When access is fragmented, managing the disease becomes more difficult, and the financial consequences can increase total medical expense.
The Centers for Disease Control and Prevention’s National Diabetes Statistics Report estimates that 40.1 million people in the United States had diagnosed or undiagnosed diabetes in 2023. Another 115.2 million adults were estimated to have prediabetes.
For payers, those numbers make diabetes more than a population health concern. They reinforce the importance of designing a health care provider network that can support members before complications become more difficult and expensive to manage.
The Financial Impact Extends Across the Network
The cost of diabetes is substantial.
The American Diabetes Association report Economic Costs of Diabetes in the U.S. in 2022 estimated the total annual cost of diagnosed diabetes at $412.9 billion in 2022. That included $306.6 billion in direct medical costs. The analysis also found that people diagnosed with diabetes had average medical expenditures 2.6 times higher than would be expected without the disease.
Those costs are not concentrated in one area of care.
Diabetes can contribute to heart, kidney, nerve, and eye problems, according to the National Institute of Diabetes and Digestive and Kidney Diseases. Preventing or managing these complications can require care from multiple parts of your payer network.
That makes provider network contracting an important financial consideration. A payer must look beyond whether enough providers have been contracted and examine whether members can move effectively through the network as their needs change.
Diabetes Care Depends on a Connected Provider Network
Managing diabetes can involve far more than periodic visits with a primary care physician.
The National Institute of Diabetes and Digestive and Kidney Diseases explains in Diabetes Management: It Takes a Team that a diabetes care team can include a broad health care team spanning primary care providers, nurses, eye doctors, diabetes care and education specialists, pharmacists, and mental health professionals.
For payers, the availability of these services matters because network gaps can disrupt the care pathway.
A member may have adequate primary care access but encounter difficulty finding an endocrinologist. Another member may receive diabetes treatment but lack convenient access to the eye care needed to monitor complications.
Network adequacy reports provide an important starting point, but they do not always reveal how easily members can move between providers or whether contracted capacity matches actual demand.
Network intelligence can give payers a more practical view of these relationships. By combining provider supply, utilization, and market data, health plans can identify where member needs may be outpacing available capacity and target provider network contracting accordingly.
Geography Should Influence Diabetes Network Strategy
The scale of diabetes risk also varies across markets.
The CDC’s National Diabetes Statistics Report provides national, state, and county-level surveillance information that can help organizations better understand where diabetes is affecting specific member populations.
That local perspective is important for provider network strategy.
A network configuration that is effective in one market may not provide sufficient capacity in another. Differences in disease prevalence, provider supply, utilization, and member demographics can change what an adequate diabetes care network looks like.
Payers should use market-specific information to determine where additional primary care or specialty capacity may be necessary. Claims patterns can also help reveal where members are receiving care and whether costly utilization may be connected to gaps elsewhere in the network.
This is where proactive network management becomes particularly valuable. Instead of waiting for member complaints or unfavorable cost trends to signal a problem, payers can use data to identify potential weaknesses earlier.
Provider Network Contracting Can Support Better Cost Management
Diabetes care also creates opportunities to examine unit cost variation.
Two providers may offer similar services at substantially different reimbursement levels. Site of care can further influence what a health plan ultimately pays.
Provider network contracting should therefore consider both access and economics.
The lowest-cost provider is not necessarily the right answer if members cannot reasonably obtain their care. At the same time, paying significantly higher rates should be supported by a clear understanding of the provider’s role in the network and the value being delivered.
TOG Network Solutions uses network intelligence to help health insurance payers examine reimbursement rates, utilization, access, and market positioning. This allows contracting teams to establish more informed negotiating guardrails while understanding how potential contract changes could affect the broader network.
For a chronic condition as prevalent as diabetes, even relatively small differences in unit cost or utilization can become significant when repeated across a large member population.
TOG’s Perspective: Look at the Full Diabetes Care Journey
A network may meet numerical adequacy requirements while still creating barriers at critical points in the member journey. Payers need visibility into where members encounter access problems and whether the provider mix reflects the actual needs of the covered population.
TOG’s network intelligence and provider network contracting services help health plans evaluate these issues before they become larger clinical or financial problems.
Three Priorities for Payers
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Look beyond primary care counts to determine whether members can access the specialty and supporting services needed to manage diabetes and its complications.
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Use prevalence, utilization, and provider data to identify markets where diabetes-related demand may exceed available capacity.
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Benchmark reimbursement and monitor utilization after contracts take effect so that network decisions support both member access and sustainable financial performance.
Diabetes is a long-term disease, and the network supporting members should be managed with the same long-term perspective.