Managed care and diabetes, with special attention to the issue of who should provide care.

Diabetes is a high-cost disease for which recent data show that intensive attention to glycemic control can reduce by half the long-term microvascular complications. The rapid rise of health care expenditures in the United States has spawned a variety of organizations and techniques to manage care and reduce costs. Inevitably these strategies impact the most costly diseases disproportionately. Among the strategies of managed care is an increasing emphasis on primary care. Considerable evidence is accumulating to indicate that primary care physicians are less well-informed about the modern standards of diabetes care that can improve outcomes. The best future care for individuals with diabetes will result from collaboration between primary care physicians and a supportive diabetes specialty team, utilizing break points to identify circumstances when the patient should move between them. Future outcomes research should focus on validations of these break points.