Standards for the care of diabetes. Origins, uses and implications for third-party payment

Standards of care are those principles that define the appropriate environment, process, and procedures necessary for quality medical care and optimal health outcomes. The initial impetus to develop standards of care came from the medical profession when it attempted to define quality of care. More recently, standards defining the medical necessity of diagnostic tests or procedures have been developed at the request of public and private third-party payors. These efforts are the natural outgrowth of two decades of health-care delivery research and technology assessment examining the effectiveness of various medical procedures. This article reviews the development of standards by the medical profession, emphasizing current standard-setting activities of private organizations and the federal government. This study examines the characteristics of a good process for developing credible medical standards to guide patient care and the payment for that care. This study also discusses how the American Diabetes Association used this process in developing standards for care of patients with diabetes mellitus and implementation problems encountered because of coverage policy of public and private health insurer programs.