Medicare: Most Beneficiaries With Diabetes Do Not Receive Recommended Monitoring Services

Published by the Government Accountability Office on 1997-03-28.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                 United States General Accounting Office

GAO              Report to the Chairman, Subcommittee
                 on Health and Environment, Committee
                 on Commerce, House of Representatives

March 1997
                 Most Beneficiaries
                 With Diabetes Do Not
                 Receive Recommended
                 Monitoring Services

      United States
GAO   General Accounting Office
      Washington, D.C. 20548

      Health, Education, and
      Human Services Division


      March 28, 1997

      The Honorable Michael Bilirakis
      Chairman, Subcommittee on Health and Environment
      Committee on Commerce
      House of Representatives

      Dear Mr. Chairman:

      Diabetes is a prevalent, costly, chronic disease that has substantial effects
      on the Medicare program: at least 1 in 10 beneficiaries is diagnosed with
      diabetes, and on average these beneficiaries cost Medicare considerably
      more than those without diabetes. Most experts agree that preventive
      care—both appropriate medical management and patient self-
      management—can improve the quality of life for people with diabetes.
      Prevention for diabetes aims to slow the disease’s progression through
      screening, monitoring, and treating conditions to keep them from
      worsening and becoming more costly.

      You asked us to examine how well the health care system provides
      preventive services to Medicare beneficiaries with diabetes. We focused
      our review on the following questions: (1) To what extent are Medicare
      beneficiaries with diabetes receiving recommended levels of preventive
      and monitoring services? (2) What are health maintenance organizations
      (HMO) that serve Medicare beneficiaries doing to improve delivery of
      recommended diabetes services? and (3) What activities does the Health
      Care Financing Administration (HCFA) support to address these service
      needs for Medicare beneficiaries with diabetes?

      To respond to these questions, we identified a representative sample of
      more than 168,000 people with diabetes in the Medicare fee-for-service
      program and reviewed their service claims records for 1994. About 90
      percent of the people with diabetes in our cohort were aged 65 or older;
      about 10 percent were under age 65 and disabled. We also surveyed 88 HMO
      plans serving Medicare beneficiaries on their approaches to preventive
      diabetes care. The plans varied in total enrollment, geographic location,
      and other characteristics. The combined Medicare enrollment of the 88
      health plans was about 2.7 million members. (For detailed descriptions of
      our methodology, see apps. I and II.)

      We also interviewed staff of 12 of the surveyed HMO plans (plans that
      reported having extensive preventive and monitoring services) and of 6

      Page 1                                     GAO/HEHS-97-48 Medicare Diabetes Care

                   disease management companies.1 In addition, we reviewed the
                   professional literature on diabetes care and discussed diabetes
                   management issues with representatives from medical specialty societies,
                   interest groups, national and regional HCFA offices, and recognized experts.
                   We conducted our work between October 1995 and November 1996 in
                   accordance with generally accepted government auditing standards.

                   Although experts agree that regular use of preventive and monitoring
Results in Brief   services can help minimize the complications of diabetes, most Medicare
                   beneficiaries with diabetes do not receive these services at recommended
                   intervals. More than 90 percent of fee-for-service Medicare beneficiaries
                   with diabetes visited their physicians at least twice in 1994; however, only
                   about 40 percent received an annual eye exam, and only about 20 percent
                   received the recommended two specialized blood tests per year to monitor
                   diabetes control.2 On the whole, these fee-for-service utilization rates did
                   not vary substantially by patient age, sex, or race. The provision of
                   preventive and monitoring services under managed care is also below
                   recommended levels, although data for this service delivery approach are
                   limited. For example, among people with diabetes aged 18 to 64 who were
                   enrolled in private HMO plans, less than half received an eye exam in 1995.
                   According to diabetes experts, several factors may contribute to low use
                   of monitoring services, including physicians’ lack of awareness of the
                   latest recommendations and patients’ lack of motivation to maintain
                   adequate self-management care.

                   Medicare HMO efforts to improve diabetes care have been varied but
                   generally limited. Most plans report that they have focused on educating
                   their enrollees with diabetes about self-management and their physicians
                   about the need for preventive and monitoring services. Some HMOs have
                   begun to take additional steps, such as tracking the degree to which
                   physicians provide preventive care, and a few plans have developed
                   comprehensive diabetes management programs. Because virtually all of
                   these efforts have begun within the past 3 years, little is known about their

                    Disease management companies are organizations, often affiliated with pharmaceutical firms, that
                   contract with employers, insurers, and HMOs to provide educational materials, individual or group
                   counseling, and sometimes service reminder systems for people with specific diseases, such as
                   diabetes or asthma.
                    The recommended eye exam for people with diabetes is a dilated, funduscopic eye examination, most
                   often performed by an ophthalmologist or optometrist. The specialized blood test is the
                   glycohemoglobin or glycosylated hemoglobin test.

                   Page 2                                                 GAO/HEHS-97-48 Medicare Diabetes Care

             HCFA also has begun to test preventive care initiatives for diabetes and has
             targeted this area for special emphasis. Its efforts include helping to plan a
             nationwide diabetes education program, encouraging local experiments to
             increase use of monitoring services and improve quality of care for people
             with diabetes, and developing performance measures for providers of
             diabetes care. But like the efforts of Medicare HMOs, HCFA’s initiatives are
             quite recent, and the agency does not yet have results that would allow it
             to evaluate effectiveness. To the extent that these initiatives prove cost-
             effective, they may help promote better management of diabetes care.

             Diabetes affects a significant portion of Medicare beneficiaries and results
Background   in an even larger share of Medicare costs. Diagnosed cases of diabetes are
             estimated to be 10 to 15 percent of the Medicare population, or roughly
             3 million to 5 million people, and nearly as many cases may be
             undiagnosed.3 According to one estimate, treating people with diabetes
             may account for as much as 25 percent of all Medicare costs.4

             People who have diabetes use more health services than nondiabetics:
             they have two to three times more ambulatory contacts (physician,
             emergency room, and hospital outpatient visits), three times more
             hospitalizations, and are more likely to live in nursing homes. Moreover,
             diabetes is the leading diagnosis associated with use of Medicare’s rapidly
             growing home health services, representing about 10 percent of all home
             health visits. In addition, complications of the disease clearly can diminish
             quality of life. Diabetes is a leading cause of blindness, end-stage renal
             disease, and lower extremity amputations; and people with diabetes have
             rates of coronary heart disease and stroke that are two to five times those
             of nondiabetics.

              Diabetes mellitus comprises a heterogeneous group of metabolic disorders characterized by high
             blood glucose (sugar) levels. Though there is no single cause of diabetes, both genetic and
             environmental or lifestyle factors—such as obesity and lack of exercise—are involved in its etiology.
             Diabetes occurs more commonly among women, minorities, and people of lower socioeconomic
             status. The two major types of diabetes are (1) insulin-dependent diabetes mellitus, known as juvenile
             or type I diabetes, and (2) noninsulin-dependent diabetes mellitus, known as adult onset or type II.
             Noninsulin-dependent diabetes accounts for about 90 percent of all cases. Despite the terminology,
             people with noninsulin-dependent diabetes may use insulin or oral medications to help control blood
             glucose levels.
              The estimated 25 percent of all Medicare costs is cited in M.I. Harris and R.C. Eastman, “Early
             Detection of Undiagnosed Non-Insulin-Dependent Diabetes Mellitus,” Journal of the American Medical
             Association, Vol. 276, No. 15 (1996), pp. 1261-62. This figure refers to Medicare costs for all services
             provided to people with diabetes, including services for conditions that may be unrelated, such as
             cancer therapy. Moreover, Medicare beneficiaries with diabetes commonly have several chronic
             conditions, adding to the cost of their care.

             Page 3                                                   GAO/HEHS-97-48 Medicare Diabetes Care

Diabetes experts generally agree that routine provision of several
preventive and monitoring services can help physicians and patients
manage the disease more effectively and control its progression. A 1993
landmark study, known as the Diabetes Control and Complications Trial
(DCCT),5 and other studies have provided evidence of opportunities for
improving care.6 The DCCT showed that improved glucose control can
retard the onset and progression of the complications of diabetes. The
American Diabetes Association’s (ADA) current recommendations for
diabetes management, the most frequently cited clinical practice
guidelines for diabetes care, reflect these studies’ results.7

Most of the ADA-recommended preventive and monitoring services are
covered benefits for Medicare beneficiaries with diabetes. Excluded as
covered benefits, however, are some services and supplies that might
facilitate active patient self-management. For example, people in
traditional, fee-for-service Medicare (about 90 percent of all beneficiaries)
bear the costs of insulin, syringes, and, in some cases, glucose test strips
used to help monitor their blood sugar levels at home.8 For those
beneficiaries enrolled in an HMO (about 10 percent of Medicare
beneficiaries nationwide), these supplies and services may or may not be
included in the benefit package, depending on the HMO. Some members of
the Congress have proposed legislation that would expand Medicare
coverage to include payment for diabetes education in an outpatient,
nonhospital-based setting, as well as payment for blood-testing strips for
all beneficiaries with diabetes.9

 The Diabetes Control and Complications Trial Research Group, “The Effect of Intensive Treatment of
Diabetes on the Development and Progression of Long-Term Complications in Insulin-Dependent
Diabetes Mellitus,” The New England Journal of Medicine, Vol. 329, No. 14 (1993), pp. 977-86. Although
this trial involved only people with insulin-dependent (type I) diabetes, there is reasonable agreement
that the results should be applied to people with noninsulin-dependent (type II) diabetes as well.
 Two studies that have confirmed the DCCT are (1) P. Reichard, M. Pihl, U. Rosenqvist, and J. Sule,
“Complications in IDDM Are Caused by Elevated Blood Glucose Level: The Stockholm Diabetes
Intervention Study (SDIS) at 10-Year Follow Up,” Diabetologia, Vol. 39 (1996), pp. 1483-88; and (2) Y.
Ohkubo, H. Kishikawa, E. Araki, and others, “Intensive Insulin Therapy Prevents the Progression of
Diabetic Microvascular Complications in Japanese Patients With Non-Insulin-Dependent Diabetes
Mellitus: A Randomized Prospective 6-Year Study,” Diabetes Research and Clinical Practice, Vol. 28
(1995), pp. 103-17.
 The ADA is a national nonprofit educational organization, whose most recent clinical guidance was
published in “Clinical Practice Recommendations 1997,” Diabetes Care, Vol. 20, suppl. 1 (1997).
 Currently, Medicare pays for 100 testing strips per month for people with diabetes who use insulin.
The consensus seems to be that the number of strips covered is adequate but that coverage should be
extended to some people with diabetes who do not use insulin.
 For example, two bills were introduced in January 1997: H.R. 15, the Medicare Preventive Benefit
Improvement Act of 1997, which includes proposed diabetes screening benefits, and H.R. 58, the
Medicare Diabetes Education and Supplies Amendments of 1997.

Page 4                                                   GAO/HEHS-97-48 Medicare Diabetes Care

                          Under both fee-for-service and HMO delivery, Medicare beneficiaries with
Medicare                  diabetes are falling far short of receiving recommended levels of
Beneficiaries With        monitoring services, according to available evidence. A number of factors,
Diabetes Are Not          both patient- and physician-related, may contribute to the low use of these
Recommended Levels
of Monitoring
Providers Agree on        The ADA clinical care guidelines reflect the published evidence and expert
Services but Recognize    opinion on what constitutes quality diabetes care. The guidelines
Need for Flexibility on   recommend monitoring services that with appropriate follow-up and
                          treatment, may lead to improved health outcomes. Receiving these
Frequencies               monitoring services, however, does not guarantee improved blood sugar
                          control or prevention of complications.

                          Nonetheless, experts generally agree that providing the monitoring
                          services recommended by the ADA represents good diabetes care. Among
                          the ADA’s recommendations for people who have noninsulin-dependent
                          diabetes (more than 90 percent of diabetics in Medicare), we selected six
                          monitoring services (see table 1) that can be measured using Medicare
                          claims data. Several other recommended services were excluded because
                          all occurrences could not be identified by this methodology. For example,
                          foot examinations to detect people at elevated risk of ulcers and infections
                          (and to prevent lower extremity amputations), when provided, are most
                          likely to be part of an office visit and if so would not be claimed as a
                          separate service.

                          Page 5                                   GAO/HEHS-97-48 Medicare Diabetes Care

Table 1: Diabetes Monitoring Services
Included in Our Analysis                                                Frequency per
                                        Service                         year                    Purpose
                                        Physician visits                Two to four             Monitor general health and diabetes
                                                                                                control, order and review lab tests,
                                                                                                conduct foot exams, and refer to other
                                        Eye exam (dilated)              One                     Identify early signs of diabetic
                                                                                                retinopathy and refer for treatment
                                        Glycohemoglobin test            Two                     Assess and monitor achievement of
                                                                                                glycemic control goals
                                        Urinalysis test                 One                     Monitor kidney function by testing for
                                                                                                albumin or protein
                                        Serum cholesterol test          One                     Monitor cholesterol as a contributor to
                                                                                                heart disease and circulatory problems
                                        Flu shot (in season)            One                     General preventive service for high-risk
                                                                                                populations such as older people and
                                                                                                people with diabetes
                                        Source: ADA, “Clinical Practice Recommendations, Standards of Medical Care for Patients With
                                        Diabetes Mellitus,” Diabetes Care, Vol. 19, suppl. 1 (1996). The annual flu shot is recommended
                                        by the American College of Physicians and supported by the Centers for Disease Control and
                                        Prevention (CDC).

                                        The recommended service frequencies specified in table 1 generally apply
                                        to the average person with noninsulin-dependent diabetes.10 However,
                                        some debate surrounds the most appropriate frequencies for certain
                                        individuals, particularly older people with diabetes: for example, whether
                                        the eye exam should be provided annually or whether providing it every 2
                                        years is just as effective. Some individuals may need more or fewer
                                        services depending on their age, medical condition, whether they use
                                        insulin, or how well their blood sugar is controlled. According to an ADA
                                        representative, a small percentage of people with diabetes could
                                        appropriately receive certain recommended services at reduced frequency.

                                         Because these are service targets, 100-percent compliance for all people with diabetes should not be

                                        Page 6                                                  GAO/HEHS-97-48 Medicare Diabetes Care

Under Fee-for-Service         Overall, our cohort of about 168,000 Medicare beneficiaries with diabetes
Care, Utilization Rates for   fell far short of receiving the recommended frequencies of the six
Recommended Services          monitoring services in 1994.11 As figure 1 shows, Medicare beneficiaries
                              with diabetes had the opportunity to receive such services because
Leave Room for                94 percent of them had at least two physician visits in 1994. In fact, the
Improvement                   mean number of physician visits was 9.5.12 However, less than half of these
                              beneficiaries with diagnosed diabetes received an eye exam (42 percent),
                              only 21 percent received the two recommended glycohemoglobin tests,
                              and only about half (53 percent) had a urinalysis.13

                                In our analysis of utilization rates for these monitoring services, we did not adjust for differences in
                              the severity of patient illness or comorbidities, which are important contributors to service use
                              variations. Some qualifications related to the use of Medicare claims data are discussed in app. I.
                                We did not determine the primary purpose of the visits, and many may have been for purposes other
                              than monitoring the patient’s diabetes.
                                Some experts observed that the service utilization rates we obtained, while low compared with
                              recommended levels, generally showed some improvement since the late 1980s and early 1990s.

                              Page 7                                                     GAO/HEHS-97-48 Medicare Diabetes Care

Figure 1: Fee-for-Service Utilization
Rates for Recommended Monitoring        Percent Receiving Services
Services, 1994                          100






















                                        Recommended Monitoring Services

                                        More Medicare beneficiaries with diabetes (70 percent) received a serum
                                        cholesterol test than any of the services except physician visits. This may
                                        reflect both the successful public education campaign of the late 1980s
                                        about cholesterol risks and the frequent inclusion of cholesterol in
                                        automated multichannel blood tests. The annual flu shot is likely to be
                                        underreported in Medicare claims data because many people receive flu
                                        shots in nonmedical settings such as shopping malls and business offices.
                                        One HCFA official estimated that Medicare claims may underreport the
                                        number of flu shots received by as much as 20 percentage points.

                                        Utilization rates are even lower when considering the monitoring services
                                        as a unit. (See fig. 2.) About 12 percent of the Medicare beneficiaries with
                                        diabetes in our cohort did not receive any of the following key monitoring
                                        services: at least one eye exam, one glycohemoglobin test,14 one urinalysis,

                                         For this analysis, we looked for only one glycohemoglobin test, instead of the recommended two,
                                        because so few beneficiaries in our cohort had received two tests.

                                        Page 8                                                                      GAO/HEHS-97-48 Medicare Diabetes Care

                                           and one serum cholesterol test. About 11 percent of beneficiaries showed
                                           Medicare claims for all four of these services.

Figure 2: Percent in Fee-for-Service
Receiving Key Monitoring Services,         100      Percent





                                            30                                 26
                                                    12                                   11


                                                     0         1       2           3      4
                                                     Number of Services Received

                                           Note: The four key services are at least one eye exam per year, one glycohemoglobin test, one
                                           urinalysis, and one serum cholesterol test.

                                           Utilization rates for the six monitoring services by patient age, sex, race,
                                           and geographic characteristics were as follows:

                                       •   Utilization rates were generally similar for men and women and for all age
                                           groups over age 65. The single most notable utilization difference was in
                                           the annual eye examination rate for people with diabetes under age 65.
                                           Forty-three percent of people with diabetes aged 65 to 74 and 44 percent
                                           of those aged 75 and older received an eye exam, compared with only
                                           28 percent of the disabled in Medicare under age 65.
                                       •   White Medicare beneficiaries with diabetes received the six monitoring
                                           services at consistently higher rates than did beneficiaries who were black
                                           or of another racial group,15 but for most services the differences were not

                                            For this analysis, we used four beneficiary race categories on the basis of those available in HCFA
                                           Medicare claims data: white, black, other (including Hispanic, Asian, and North American Natives),
                                           and unknown.

                                           Page 9                                                   GAO/HEHS-97-48 Medicare Diabetes Care

                               great. For example, the utilization rate for the eye exam was 43 percent for
                               whites, 36 percent for blacks, and 37 percent for beneficiaries of other
                               races. The rate for at least one glycohemoglobin test was 39 percent for
                               whites, 31 percent for blacks, and 37 percent for beneficiaries of other
                           •   The use of diabetes monitoring services varied by geographic area. For
                               example, among the 10 states that had the largest Medicare fee-for-service
                               diabetes populations in our study, Florida and New York had the highest
                               percentages of beneficiaries with diabetes who received all four key
                               services, at 18 and 16 percent, respectively; Pennsylvania had the lowest
                               rate, 8 percent. As another example of this variation, of all 50 states and
                               the District of Columbia, Nebraska had the highest eye exam rate
                               (54 percent), and Alabama had the lowest (32 percent), followed by
                               Tennessee and Oregon (33 percent).
                           •   Seventy-four percent of our Medicare fee-for-service diabetes cohort lived
                               in Metropolitan Statistical Areas (MSA) and the remaining 26 percent lived
                               in non-MSAs, generally rural areas. Monitoring services’ utilization rates
                               were slightly but consistently higher for beneficiaries living in MSAs, as a
                               whole, than for those living outside MSAs.

                               (Detailed data on service utilization rates by these characteristics appear
                               in app. I.)

Limited Data Suggest           Because HCFA does not require its HMO contractors to report patient-
Monitoring in Medicare         specific utilization data, we could not systematically assess the use of
HMOs Also Falls Short of       recommended monitoring services by beneficiaries with diabetes in
                               Medicare HMOs. Unlike fee-for-service providers, Medicare HMOs are paid a
Recommendations                monthly rate per enrollee, regardless of the actual services provided.
                               Therefore, to be paid, the plans do not need to document utilization, costs
                               of care, or patient case mix. Individual plans, however, may develop such
                               information for in-house management purposes.

                               Diabetes monitoring services’ utilization rates are also below
                               recommended levels in Medicare HMOs, according to the limited data we
                               obtained from published research and other sources. For example, the HMO
                               component of HCFA’s Ambulatory Care Diabetes Project, including 23
                               health plans that volunteered as project participants in five states
                               (California, Florida, Minnesota, New York, and Pennsylvania), determined
                               that 61 percent of Medicare enrollees received an eye exam in an 18-month
                               period ending in 1995; 69 percent received at least one glycohemoglobin

                               Page 10                                   GAO/HEHS-97-48 Medicare Diabetes Care

                        Another indicator of the level of monitoring services provided to people
                        with diabetes in HMOs is the eye exam rate reported in the Health Plan
                        Employer Data and Information Set (HEDIS), a standardized, voluntary HMO
                        performance reporting system developed by the National Committee on
                        Quality Assurance (NCQA). HEDIS data are the most commonly used HMO
                        performance measures for the non-Medicare, employer-insured HMO
                        population. Nationwide, the average diabetic eye exam rate reported by
                        HMOs participating in HEDIS was 42 percent in 1995, but the rate varied
                        widely among the few plans whose reports we obtained, ranging from 20
                        to 70 percent. Although it is unclear whether these rates also apply to
                        Medicare beneficiaries with diabetes enrolled in HMOs, the national average
                        rate of 42 percent was the same rate we found in our 1994 Medicare
                        fee-for-service population.

Patient and Physician   Although it is unclear what specifically accounts for the less-than-
Factors Contribute to   recommended use of monitoring services, diabetes experts have identified
Less-Than-Recommended   several factors, including patient and physician attitudes and practices,
                        that contribute to suboptimal diabetes management in general. Many of
Utilization             these factors are not unique to diabetes management; they also affect
                        delivery of preventive care for many other chronic conditions.

                        Experts agree that the patient bears much of the responsibility for
                        successful diabetes management. For a variety of reasons, however,
                        people with diabetes may not actively manage their disease. Lack of
                        knowledge, motivation, and adequate support systems are often cited as
                        key reasons. People with diabetes may not fully understand the
                        seriousness of their disease or the need for regular preventive and
                        monitoring services. Consequently, they may not always follow up on
                        routine appointments and referrals. For many, diabetes self-management
                        does not become a priority until serious complications develop. Then,
                        difficult changes in well-established habits, such as diet, lack of exercise,
                        and smoking, may be needed. A family support system is important to help
                        patients make such changes, but it is often lacking.

                        Experts have also noted that the substantial out-of-pocket costs for people
                        with diabetes—that can result from incomplete insurance coverage for
                        diabetes-related supplies, such as insulin, syringes, and glucose-testing
                        strips—may discourage some people with diabetes from actively managing
                        their disease. For example, syringes may cost about $10 to $15 per 100,
                        insulin costs about $40 to $70 for a 90-day supply, glucose-testing meters

                        Page 11                                   GAO/HEHS-97-48 Medicare Diabetes Care

                         cost from $50 to $100, and glucose-testing strips cost $.50 to $.72 each (or
                         about $1,000 a year for a person with diabetes who tests four times a day).

                         Physicians and other health care providers also may contribute to low
                         utilization rates for recommended services, according to literature reports
                         and experts we contacted. Some physicians may not be well versed in the
                         latest diabetes care guidelines, or they may not know of recent research
                         demonstrating the efficacy of treatments. Others may disagree with the
                         need for all recommended services for all patients or, specifically, with the
                         recommended frequency of services. Some physicians may be discouraged
                         from active diabetes management with older patients because, though
                         some monitoring services may identify complications, they do not prevent
                         them; and without patient behavior changes, health outcomes are unlikely
                         to improve.

                         Another important factor affecting physician practices is the severity of a
                         patient’s diabetes and the extent of other medical problems. Many
                         Medicare beneficiaries with diabetes have several serious medical
                         conditions. We were told that during a patient visit, a physician is likely to
                         focus on a patient’s most urgent concerns, neglecting ongoing diabetes
                         management and patient education.

                         Finally, inadequate support systems for many providers may contribute to
                         less-than-recommended service delivery, according to some reports.
                         Managed care plans and physician practices may lack automated medical
                         records and service-tracking systems that could provide timely records of
                         patient service use and reminders when routine preventive and monitoring
                         services, such as those for diabetes, are needed.

                         Collectively, the 88 HMOs in our survey reported a wide range of diabetes
HMO Efforts to           management efforts; in general, however, most plans’ efforts are limited.
Manage Diabetes Care     The HMOs identified more than 30 different kinds of diabetes management
Are Varied but Limited   activities, ranging from featuring articles on diabetes in their publications
                         to monitoring the degree to which their physicians are providing
                         preventive services.16 The type and number of reported activities varies
                         greatly: a few HMOs have comprehensive diabetes management programs,
                         but most plans’ efforts are much more limited. HMOs told us that they have
                         focused their efforts on educating people with diabetes about self-
                         management and their physicians about the need for recommended

                           For details about these approaches and their use by HMOs according to size, model type, geographic
                         location, and tax status (profit or nonprofit), see app. II. In general, we did not find strong associations
                         between the types of approaches used and specific HMO characteristics.

                         Page 12                                                    GAO/HEHS-97-48 Medicare Diabetes Care

                                 preventive and monitoring services. Even HMOs with comprehensive
                                 diabetes management programs have initiated their efforts mostly in the
                                 past 3 years. As a result, little is known yet about the effectiveness of these
                                 efforts or which approaches work better than others.

                                 Although we did not survey fee-for-service group practices on their
                                 diabetes management approaches, several of these groups also may be
                                 exploring ways to improve diabetes care in response to the DCCT research
                                 findings and practice guidelines. For example, one multispecialty group
                                 practice has established a comprehensive diabetes education and
                                 treatment center, and another group told us they have started to monitor
                                 utilization of the diabetic eye exam and have implemented a quality-
                                 improvement program to increase utilization.

Most Efforts to Date Focus       Every HMO in our survey reported using at least one type of effort to
on Education                     educate enrollees with diabetes about appropriate diabetes management.
                                 Following are examples of the kinds of approaches they reported:

                             •   Written materials: The most common approach (used by 82 of the 88
                                 plans) is featuring articles about diabetes management in publications
                                 directed to all enrollees. Other approaches include placing brochures
                                 about diabetes management in physicians’ waiting rooms and making a
                                 comprehensive manual on diabetes care available to all enrollees with
                             •   One-on-one educational sessions: Sixty-eight HMOs reported having
                                 diabetes-related health professionals, such as nurses, certified diabetes
                                 educators, or other specialists, provide diabetes education to individuals
                                 with diabetes. During our follow-up interviews with 12 plans,17 the HMOs
                                 reported a wide variety of approaches to educating such enrollees, from
                                 regular meetings with experts on exercise and nutrition to a telephone-
                                 advice service that fields enrollees’ questions about diabetes.
                             •   Classes: During our follow-up interviews, we learned that a number of
                                 HMOs offer classes for several levels of diabetes education: basic classes
                                 for people newly diagnosed with diabetes, intermediate classes to provide
                                 ongoing management support, and advanced classes for people with
                                 diabetes who want to learn how to closely control their blood sugar levels.

                                 Besides educational efforts for enrollees, most HMOs said they also had
                                 begun educational efforts for physicians. Commonly used techniques to

                                   We selected 12 of the 88 surveyed plans for additional, follow-up interviews. The plans we selected
                                 reported providing extensive preventive and monitoring services. We collected some of the material in
                                 this section during these follow-up interviews.

                                 Page 13                                                 GAO/HEHS-97-48 Medicare Diabetes Care

                        educate physicians on the importance of preventive care include sending
                        written materials (reported by 71 plans) and holding meetings with groups
                        of physicians (46 plans). Nearly three-fourths of the HMOs reported using
                        clinical practice guidelines on diabetes care.18 Some supplement these
                        guidelines with more intensive education. For example, one HMO reported
                        that its endocrinologists meet regularly with small groups of primary care
                        physicians to provide training on important diabetes topics, such as
                        diabetic eye disease and foot care. The plan has also developed a
                        physician training video on diabetic foot care.

                        Some of the HMOs—10 of the 88 we surveyed—contract with disease
                        management companies to provide diabetes education services. One such
                        company, for example, offers what they call three platforms of services:
                        (1) educational mailings, (2) telephone-based education and counseling,
                        and (3) face-to-face education and counseling. For a fixed, per person,
                        monthly fee, which varies by the platform selected by the contracting
                        group, the disease management company provides services to any of the
                        plan’s enrollees with diabetes who choose to participate.

Many Plans Are          Although education may effect short-term behavioral changes, some
Augmenting Education    experts express concern about the difficulty people with diabetes and
With Other Approaches   physicians have in maintaining behavioral changes. Information about
                        managing diabetes is essential to good control of blood sugar levels, but
                        information alone may not be enough to motivate the behavior and
                        lifestyle changes necessary to maintain such control. For example, one
                        diabetes expert told us that many people with diabetes revert to old
                        behaviors within 6 months unless they receive additional education or
                        support. As the director of diabetes clinical research at a large
                        pharmaceutical firm put it, “the successful implementation of good
                        diabetes management, through good control of blood sugar levels, can
                        only be achieved through significant daily changes in lifestyle by the
                        diabetic. This is very hard to do.”

                        HMOs reported using a wide variety of approaches to continuously
                        encourage appropriate diabetes management. Following are some of the
                        approaches they reported:

                          Some relationship does exist between the type of approach and a characteristic of the HMO,
                        according to our analysis: the greater the number of Medicare enrollees, the higher the likelihood that
                        the HMO has a clinical practice guideline. Forty-six percent of HMOs with less than 10,000 Medicare
                        enrollees reported having such a guideline, compared with 84 percent of HMOs with 20,001 to 50,000
                        Medicare enrollees and 92 percent with more than 50,000 enrollees.

                        Page 14                                                  GAO/HEHS-97-48 Medicare Diabetes Care

•   Reminders to enrollees and physicians: About half of the HMOs reported
    one or more such efforts. For example, one HMO provides a small, wallet-
    sized “scorecard” to enrollees with diabetes that lists recommended
    annual services and has a chart for enrollees to record the dates they
    receive each service. One HMO posts signs in examining rooms reminding
    people with diabetes to remove their shoes and socks to prompt
    physicians to check patients’ feet, and another attaches service reminder
    sheets to enrollees’ charts when they come in for any visit.
•   Performance monitoring and feedback: Many health plans are trying to
    improve preventive care utilization rates by providing feedback to
    physicians on their compliance with recommended standards. Of the 62
    plans that reported use of a clinical practice guideline for diabetes, 52 have
    a system to monitor physicians’ compliance with it. The plans are most
    likely to monitor utilization of services related to HEDIS reporting
    requirements, and some reported systems to convey such utilization
    results to their physicians.19
•   Diabetes registries: HMOs reported maintaining regularly updated registries
    of their enrollees with diabetes to monitor overall compliance with
    recommended standards and to mail them information and appointment
    reminders. For example, one HMO uses its registry and its claims records to
    mail a reminder letter to enrollees who have not received an eye exam in
    the past year. Another plan combines its diabetes registry with pharmacy,
    laboratory, and billing data, all of which can be accessed by physicians to
    review a patient’s use of services and determine which services should be
•   Diabetes clinics: A few HMOs reported offering regular comprehensive
    diabetes care clinics. This involves the HMO setting aside days when people
    with diabetes can see their physicians, a nutritionist, a podiatrist, and
    other specialists and receive all necessary laboratory services in a single
    visit. One HMO reported the hope that these clinics would encourage
    self-sustaining diabetes support groups, while reducing the number of
    physician office visits.
•   Support systems: One HMO has been providing education and support to
    Medicare beneficiaries who have diabetes or asthma through a voluntary,
    confidential, toll-free telephone system. Nurse counselors trained in these
    chronic diseases answer health care questions, provide education, and
    encourage self-management skills.

    Five of the HMOs reported committing substantial resources to develop a
    systemwide comprehensive diabetes management program. For example,

     To monitor HEDIS performance measures, the plans collect data according to NCQA specifications,
    using chart reviews, claims or encounter data, or a combination of both.

    Page 15                                              GAO/HEHS-97-48 Medicare Diabetes Care

                            one HMO we contacted has established a population-based approach to
                            diabetes management, with long-term goals of improving patient health
                            status and satisfaction as well as performance on cost and utilization. The
                            HMO measures patient outcomes with both clinical and subjective values,
                            which range from improved blood glucose control and prevention of
                            microvascular disease to the patient’s assessment of improved quality of
                            life and sense of well-being. The plan relies on a variety of interventions to
                            meet enrollees’ needs, including diabetes chronic care clinics at several
                            family practice sites, patient self-management notebooks, and diabetes
                            telephone education. Interventions designed to help physicians provide
                            better care to enrollees with diabetes include an online diabetes registry
                            for physicians that is updated monthly, use of evidence-based clinical
                            practice guidelines, outcomes reports for physicians, and provider
                            education and training by diabetes expert teams consisting of an
                            endocrinologist and a nurse. These teams travel to all family practice sites
                            several times each year to see patients jointly with the family practice

Little Evidence Available   HMOs in our survey generally had little information about the extent to
on Effectiveness of         which their diabetes management approaches have affected the use of
Diabetes Management         recommended monitoring services. Even the plans reporting the most
                            comprehensive approaches told us that they collect utilization data on five
Efforts                     or fewer services and began collecting this information in 1993 or 1994.
                            Some HMOs said they collect no such data. The service monitored most
                            often (by 58 HMOs) was the diabetic eye exam, probably because HEDIS, the
                            performance-reporting system for commercial HMOs, requires plans to
                            measure the percentage of their enrollees with diabetes under age 65 who
                            receive an annual eye exam.

                            Although little information exists on the relative effectiveness of specific
                            approaches, most experts generally believe that intensive and sustained
                            interventions are most likely to support long-term behavior change. For
                            example, one disease management company told us that its in-person
                            counseling and education program is likely to be more effective at
                            improving utilization rates than communicating with enrollees by
                            telephone or mailings. Because intensive interventions are probably more
                            expensive to provide than other approaches, measuring their effectiveness
                            is important.

                            Of the 88 plans surveyed, 13 reported having information about the effect
                            of their diabetes management efforts on the service use or health

                            Page 16                                    GAO/HEHS-97-48 Medicare Diabetes Care

                             outcomes of their enrollees with diabetes or on the costs to their plans.
                             This is largely because most diabetes management programs are relatively
                             new, and plans do not have systems established to collect and analyze data
                             on outcomes or cost. From the plans that reported information about the
                             effectiveness of their diabetes management efforts, we heard the

                         •   Using a variety of strategies, one HMO has shown improved utilization and
                             outcomes. Annual eye examinations increased from 47 percent of
                             enrollees with diabetes in 1994 to 53 percent in 1995, and glycohemoglobin
                             test results showed that the percentage of enrollees with diabetes in good
                             or optimal control improved from 35 to 39 percent.
                         •   Officials of another HMO believe that increased utilization of annual eye
                             exams and glycohemoglobin testing, measured over a 2-year period, are
                             attributable to a program that includes mailings to people with diabetes
                             and an annual performance report for physicians. To increase utilization of
                             the eye exam, the HMO used its diabetes registry to identify 24,000 enrollees
                             with diabetes who had no record of ever receiving an eye exam. After
                             sending letters to those enrollees and their physicians, the plan found that
                             2,640, or 11 percent, went for an eye exam within 3 months, and, as a
                             result, 48 were referred for appropriate treatment.
                         •   One HMO found that enrollees’ glycohemoglobin values improved by
                             16 percent after the HMO established a diabetes management program,
                             including a 2-day self-management class for enrollees newly diagnosed
                             with diabetes, quarterly follow-ups with a certified diabetes educator or
                             registered nurse, quarterly reminder letters about scheduling
                             appointments, and a communication system for the plan’s
                             multidisciplinary diabetes team. According to plan officials, in many cases,
                             their enrollees were able to stop taking insulin and control their diabetes
                             with other methods.

                             HCFA has identified diabetes as a major health problem in the Medicare
HCFA Has Targeted            population and has targeted the disease for special initiatives to improve
Diabetes for Special         physician and patient awareness, service delivery, and, ultimately, patient
Initiatives, but             health outcomes. As in the private sector, however, most of HCFA’s
                             diabetes management initiatives are either new or not yet under way;
Effectiveness Is Still       therefore, clear evidence on which approaches are most effective is not
Largely Unknown              yet available. In addition, some experts suggest that the agency should do
                             more to encourage improved diabetes management.

                             Page 17                                   GAO/HEHS-97-48 Medicare Diabetes Care

Diabetes Education and             Four years ago, HCFA officials crafted a strategic plan for the agency that
Service Delivery Initiatives       was designed to move it from its traditional role as a payer to that of a
Have Begun                         responsible, value-based purchaser. HCFA’s mission includes not only
                                   protecting the fiscal soundness of HCFA programs, but also ensuring access
                                   to affordable, quality health services for its beneficiaries to improve their
                                   health status. To this end, HCFA officials determined that diabetes care was
                                   a suitable target for action initiatives.

                                   HCFA  has started several types of initiatives designed to educate
                                   beneficiaries and physicians about diabetes management and to encourage
                                   increased use of recommended services. These initiatives are based on the
                                   belief that if beneficiaries and providers know about the steps involved in
                                   effectively managing diabetes, and if systems are in place to help remind
                                   them when certain services are needed, then both may take a more active
                                   role in ensuring that appropriate diabetes services are delivered.
                                   Following are some of HCFA’s initiatives in this area:

                               •   Nationwide Diabetes Education Program: HCFA is actively participating in
                                   the National Diabetes Education Program, organized by CDC and the
                                   National Institute of Diabetes and Digestive and Kidney Diseases, part of
                                   the National Institutes of Health. This program is designed to increase
                                   general public awareness of diabetes as well as patient and provider
                                   education about diabetes and practice guidelines. A draft program plan is
                                   expected by June 1997.
                               •   Local projects to encourage utilization: HCFA contracts with peer review
                                   organizations (PRO) to conduct local projects to improve the quality of care
                                   for Medicare beneficiaries.20 Working with the HCFA regional offices, PROs
                                   currently are required to implement at least one diabetes-related
                                   quality-improvement project involving the providers in their states.
                                   Twenty-one PROs have reported a total of 33 diabetes-related projects now
                                   under way. For example, the PRO in the state of Washington has developed
                                   a method, using Medicare claims data, for identifying beneficiaries with
                                   diabetes who are at high risk of lower extremity amputations and
                                   encouraging them to get therapeutic shoes to prevent such complications.
                                   In addition to fee-for-service quality projects, many PROs are working with
                                   HMOs to develop strategies for improving diabetes care, including patient
                                   information mailings and physician reminder systems. In Arizona, the PRO
                                   has collected baseline data on 15 quality indicator services from six
                                   participating HMOs. Together, they have implemented a variety of
                                   interventions, including the creation of diabetes databases, special referral

                                    PROs generally are private, nonprofit organizations of physicians and health professionals, with each
                                   PRO covering one or more states. Many PROs are coordinating their diabetes efforts with CDC’s
                                   Diabetes Control Programs in various states.

                                   Page 18                                                 GAO/HEHS-97-48 Medicare Diabetes Care

                           and education for noncompliant patients, and the provision of diabetes
                           services to homebound patients. After 1 year of implementation, the
                           quality indicators services have improved by 38 percent.
                       •   Multistate evaluation of intervention strategies: HCFA’s Ambulatory Care
                           Diabetes Project involves fee-for-service and HMO providers and PROs in
                           eight states. The two-part project has completed baseline data collection
                           on diabetes service utilization. The intervention stages have been
                           completed, and the remeasurement phase began on January 1, 1997.
                           Participating HMOs have been developing a wide variety of interventions
                           not limited to education, such as reminders to enrollees and physicians
                           and special incentives for beneficiaries.

HCFA Is Preparing to       HCFA  also has committed to encouraging the development of better data-
Implement Other            collection systems for tracking service use. The agency is planning several
Initiatives                initiatives to develop better information on utilization:

                       •   Application of HEDIS performance measures in Medicare: This year, for the
                           first time, HCFA will require its HMO risk and cost contractors to report the
                           new HEDIS 3.0 performance measures, including the diabetic eye exam rate
                           and flu shot rate. A measure of the glycohemoglobin test may be added in
                           the future. HCFA eventually plans to release this information as part of a
                           comparative “report card” on Medicare HMOs to help beneficiaries choose
                           among plans.
                       •   Expansion of performance measurement to include fee-for-service: HCFA is
                           considering pilot tests to determine the feasibility of expanding
                           performance measurement to include fee-for-service beneficiaries in
                           addition to HMO beneficiaries. Such an expansion would most likely
                           include the diabetes measures used in HMO plans and examine
                           performance at both the community level and for beneficiaries receiving
                           care from large group practices.
                       •   Development of other measurement systems: HCFA is supporting the
                           development of other process- and outcomes-based performance-
                           measurement systems for monitoring diabetes care. Specifically, HCFA
                           awarded a contract to the RAND Corporation to refine quality-of-care
                           measures, including diabetes measures, developed by the Foundation for
                           Accountability.21 These measures may be tested in Medicare HMOs and
                           fee-for-service in 1997, and, if successful, HCFA may consider adopting
                           them as a reporting requirement in 1998.

                            The Foundation for Accountability is an independent organization of consumers and public and
                           private health care payers that promotes the use of patient-oriented measures of health care quality.

                           Page 19                                                  GAO/HEHS-97-48 Medicare Diabetes Care

              •   Registry of beneficiaries: HCFA’s Office of Research and Demonstrations is
                  planning an ongoing registry of a representative sample of Medicare
                  beneficiaries in fee-for-service and HMOs that would provide a study
                  population for regular surveys of health status, health history, and
                  socioeconomic and functional status. This new program would provide a
                  valuable database for a wide range of studies, including research on the
                  chronically ill, such as people with diabetes.

                  Because several of HCFA’s diabetes management initiatives have started
                  only recently, and others are still in the planning stages, it is not yet
                  possible to determine which of these projects are most likely to be
                  effective. Some experts have suggested that HCFA should do more,
                  including the following:

              •   test the effects of easing potential barriers to active diabetes self-
                  management, such as the current limitations on coverage of supplies
                  (including blood-testing strips) and diabetes self-management education;
              •   implement incentive systems to reward physicians for achieving and
                  maintaining practice changes that promote better health outcomes;22
              •   test diabetes management programs, such as mailed reminder cards or a
                  telephone counseling service, with voluntary Medicare patient
                  participation; and
              •   support provider-certification programs specifically for diabetes care that
                  are being developed by professional organizations.

                  Diabetes care is a microcosm of the challenges facing the nation’s health
Conclusions       care system in managing chronic illnesses among the elderly. The
                  prevalence and high cost of diabetes make it an opportune target for
                  better management efforts. When beneficiaries receive less than the
                  recommended levels of preventive and monitoring services, the result may
                  be increased medical complications and Medicare costs. On the other
                  hand, following the recommendations may enhance beneficiaries’ quality
                  of life.

                  Effectively managing diabetes is hard to accomplish, however, and
                  requires a concerted effort by beneficiaries and physicians. People with
                  diabetes often do not understand or fully appreciate the seriousness of
                  their disease nor the potential for serious complications. Physicians,

                   HCFA is planning to test an outcomes-based reimbursement incentives approach that eventually may
                  be applied to diabetes. In a demonstration involving anticoagulation therapy, HCFA plans to establish
                  an incentive payment to providers based on documentation of good patient outcomes, rather than on
                  physician compliance with recommended processes of care.

                  Page 20                                                GAO/HEHS-97-48 Medicare Diabetes Care

                   whether in fee-for-service or managed care, may not take all steps
                   necessary to ensure that their patients with diabetes receive
                   recommended preventive care. Among HMOs, where coordinated care and
                   prevention are expected to receive special emphasis, many plans are
                   exploring ways to improve diabetes management through reminder
                   systems, telephone hot lines, incentive programs, group clinics, and other
                   approaches. In general, however, providers may be reluctant to invest in
                   more targeted and expensive approaches until their cost-effectiveness is
                   more evident. Recognizing the importance of this issue, HCFA has initiated
                   a reasonable and promising strategy of testing a variety of approaches to
                   learn what works in Medicare—that is, what is effective and what can be
                   implemented at reasonable cost.

                   HCFA  officials generally agreed with the information and issues discussed
Agency Comments    in a draft of this report, noting that, “interventions to prevent the
and Our Response   progression of early complications . . . [that] cause significant morbidity
                   are of key importance to this high risk population.” They raised one
                   conceptual issue on the appropriate quality of care for elderly diabetes
                   patients. Most Medicare beneficiaries with diabetes have had the disease
                   for many years and are likely to have other serious chronic conditions.
                   Therefore, the appropriate frequency of certain monitoring services, such
                   as glycohemoglobin testing, should depend on the treatment regimen for
                   an individual patient, rather than a generic recommendation. HCFA officials
                   also provided a number of technical suggestions that we incorporated
                   where appropriate. A copy of HCFA’s comments appears in appendix III.

                   We recognize that the service and frequency recommendations in the ADA
                   guidelines are not standards to be applied absolutely to every Medicare
                   beneficiary with diabetes but represent good care for an average person.
                   Because we examined the records for more than 168,000 Medicare
                   beneficiaries, we believe our conclusions on aggregate underperformance
                   of preventive and monitoring services are accurate.

                   In addition, we obtained comments on our draft report from several
                   experts in diabetes care and public health. They generally agreed with our
                   finding that the use of diabetes preventive and monitoring services could
                   be improved. Like HCFA officials, they observed that differences among
                   individuals with diabetes may justify some variation in the use of
                   recommended services. We responded to these points and incorporated
                   technical comments as appropriate.

                   Page 21                                  GAO/HEHS-97-48 Medicare Diabetes Care

As arranged with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days from the
date of this letter. At that time, we will send copies to interested parties
and make copies available to others on request. Please call me on
(202) 512-7119 if you or your staff have any questions. Major contributors
to this report are listed in appendix IV.

Sincerely yours,

Bernice Steinhardt
Director, Health Services Quality
  and Public Health Issues

Page 22                                    GAO/HEHS-97-48 Medicare Diabetes Care
Page 23   GAO/HEHS-97-48 Medicare Diabetes Care

Letter                                                                                             1

Appendix I                                                                                        26
                        Selecting a Diabetes Cohort From Medicare Fee-for-Service Data            26
Methodology for           Files
Determining Use of      Adding Enrollment and Eligibility Data to Diabetes Cohort                 27
Recommended             Identifying and Counting Recommended Diabetes Services                    27
Diabetes Services in
Appendix II                                                                                       35
                        Methodology                                                               35
Methodology for         Survey Results                                                            37
Determining Use of
Diabetes Management
Approaches by
Medicare HMOs
Appendix III                                                                                      40

Comments From the
Health Care Financing
Appendix IV                                                                                       42

Major Contributors to
This Report
Tables                  Table 1: Diabetes Monitoring Services Included in Our Analysis             6
                        Table I.1: Diabetes Cohort Demographic Characteristics                    29
                        Table I.2: Overall Utilization Rates for Recommended Services             30
                        Table I.3: Utilization Rates for Recommended Services, by Age             30
                        Table I.4: Utilization Rates for Recommended Services, by Race            31
                        Table I.5: Utilization Rates for Recommended Services, by Sex             31

                        Page 24                                 GAO/HEHS-97-48 Medicare Diabetes Care

          Table I.6: Combined Utilization Rates for Four Key Services, by           32
            Diabetes Cohort Demographic Characteristics
          Table I.7: Utilization Rates for Recommended Services, by State           33
          Table II.1: Characteristics of HMO Plans in Our Survey                    36
          Table II.2: HMO Responses to Selected Survey Questions                    37
          Table II.3: Diabetes Interventions Reported by HMOs                       38
          Table II.4: HMOs Efforts to Monitor Recommended Services by               39
            Plan Characteristic

Figures   Figure 1: Fee-for-Service Utilization Rates for Recommended                8
            Monitoring Services, 1994
          Figure 2: Percent in Fee-for-Service Receiving Key Monitoring              9
            Services, 1994


          ADA        American Diabetes Association
          CDC        Centers for Disease Control and Prevention
          DCCT       Diabetes Control and Complications Trial
          HCFA       Health Care Financing Administration
          HEDIS      Health Plan Employer Data and Information Set
          HMO        health maintenance organization
          MSA        Metropolitan Statistical Area
          NCQA       National Committee on Quality Assurance
          PRO        peer review organization
          SAF        Standard Analytical File

          Page 25                                 GAO/HEHS-97-48 Medicare Diabetes Care
Appendix I

Methodology for Determining Use of
Recommended Diabetes Services in
Fee-for-Service Medicare
                       A 1995 HCFA study of eye examinations for Medicare beneficiaries with
                       diabetes in the state of Washington provided a model for identifying
                       people with diabetes and specific services in the Medicare claims data. We
                       modified that model to address our research question on the basis of
                       published research in the field, consultation with HCFA officials involved in
                       similar studies and a Medicare part B carrier, and input from an informal
                       panel of expert reviewers.

                       The analysis was performed in three steps: (1) selecting a cohort of
                       Medicare beneficiaries with diabetes, (2) adding beneficiary data to select
                       only people who were enrolled in Medicare fee-for-service and part B
                       during the entire study period, and (3) analyzing cohort characteristics and
                       1994 service utilization rates. This appendix describes the general
                       methodology and results.

                       We used HCFA’s 5% Sample Beneficiary Standard Analytical File (SAF) to
Selecting a Diabetes   obtain a nationwide representative sample of Medicare beneficiaries. This
Cohort From            file contains final action claims data for a 5-percent sample of Medicare
Medicare               beneficiaries. We determined that this file would provide a sufficient
                       number of claims from which to select a representative sample of
Fee-for-Service Data   Medicare fee-for-service beneficiaries with diabetes. We limited this part
Files                  of our analysis to two parts of the 5% Sample Beneficiary SAF—Inpatient
                       Data and Physician/Supplier Data—for calendar years 1992 and 1993.23 We
                       did this because our selection criteria involved only inpatient hospital and
                       physician services. To be selected for our cohort, a beneficiary had to have
                       had at least one inpatient hospital admission or two physician visits coded
                       for diabetes.

                       Because we wanted to measure the extent to which Medicare beneficiaries
                       with diabetes received recommended medical services, we selected only
                       beneficiaries we could positively identify as having diabetes. HCFA officials
                       advised us that hospital inpatient claims noting a diagnosis of diabetes
                       were reliable. Therefore, we required only one hospital inpatient
                       admission for selecting a beneficiary.

                       Physician/Supplier Data, however, might note a diabetes diagnosis when a
                       beneficiary was being tested for diabetes, even if the test result was
                       negative. Therefore, to avoid selecting people without diabetes, we
                       required beneficiaries to have had at least two physician visits with a

                         We identified our diabetes cohort from 1992 and 1993 claims data, then reviewed cohort member
                       claims in 1994 for service utilization rates.

                       Page 26                                               GAO/HEHS-97-48 Medicare Diabetes Care
                          Appendix I
                          Methodology for Determining Use of
                          Recommended Diabetes Services in
                          Fee-for-Service Medicare

                          diagnosis of diabetes before selecting them on the basis of physician visits
                          alone.24 To eliminate selections based on a physician office visit (claim
                          1) and a laboratory or other procedure arising from the same visit (claim
                          2), we selected only claims coded as “face-to-face” physician visits.

                          After adding enrollment and eligibility data to our diabetes cohort records,
Adding Enrollment         we could delete certain beneficiary groups from our sample. First, we
and Eligibility Data to   excluded all beneficiaries with a date of death on or before December 31,
Diabetes Cohort           1994, because these people would not have had a complete year’s service
                          history for 1994. We also excluded beneficiaries who were not enrolled in
Records                   part B (for coverage of physician services) for all of 1994. They might have
                          received services for which they paid themselves, and Medicare would
                          have had no record of the services. Likewise, we excluded beneficiaries
                          who were enrolled in an HMO at any time during the year because Medicare
                          would have had no claims records for the services they received while in
                          the HMO. Finally, after reviewing preliminary data, we excluded (1) end-
                          stage renal disease beneficiaries because we could not determine whether
                          some services we were looking for had been put under a different
                          procedure code and (2) beneficiaries with diabetes living outside the 50
                          states and the District of Columbia.

                          During this step, we also resolved changes in beneficiary identification
                          numbers and obtained current residence and demographic data. We used
                          the Enrollment Data Base and Health Insurance Skeleton Eligibility Write-
                          Off files for this purpose.

                          The last step was to determine the services received by our diabetes
Identifying and           cohort in 1994 by comparing the cohort with the 1994 5% Sample
Counting                  Beneficiary SAF. This time, we checked all six component claims files:
Recommended               Inpatient, Hospital Outpatient, Physician/Supplier, Skilled Nursing Facility,
                          Home Health, and Hospice. We also checked a special file of influenza
Diabetes Services         vaccinations developed by HCFA.

                           As with inpatient claims, we accepted any of the ICD-9-CM codes to identify diabetes (the 250 codes),
                          plus a few codes for diabetes-related conditions. ICD-9-CM is the International Classification of
                          Diseases, 9th revision, Clinical Modification (5th edition, 1996), the standard coding system used for
                          medical conditions.

                          Page 27                                                 GAO/HEHS-97-48 Medicare Diabetes Care
    Appendix I
    Methodology for Determining Use of
    Recommended Diabetes Services in
    Fee-for-Service Medicare

    We searched the claims files for procedure codes for six diabetes
    preventive and monitoring services recommended by the American
    Diabetes Association (ADA):25

•   physician visits,
•   glycohemoglobin test,
•   dilated eye examination,
•   urinalysis,
•   serum cholesterol test, and
•   influenza vaccination.

    We determined the number of beneficiaries in our cohort who received
    each of the services as well as combinations of services. These numbers
    provided numerator data to calculate the percentage of cohort members
    with diabetes who received the services at recommended intervals. The
    denominator was the total number of beneficiaries with diabetes that we
    identified in our final cohort (that is, the 168,255 beneficiaries who were
    alive through 1994 and continuously enrolled in Medicare part B and
    fee-for-service). We analyzed the six service utilization rates by patient
    age, race, sex, Medicare eligibility category, and state and Metropolitan
    Statistical Area of residence. Tables I.1 to I.7 provide detailed data from
    some of these analyses, along with a demographic description of the final
    1994 Medicare fee-for-service diabetes cohort.

    Determining service utilization rates using Medicare claims data presents
    potential sources of bias. On the one hand, rates based on services
    identified in the claims data may underestimate actual utilization because
    claims or billing data may be miscoded, incomplete, or missing. When
    people receive services in nonmedical settings or if for any reason a bill is
    not submitted to Medicare, no record of the service appears in claims data.
    We believe influenza vaccination is the service most affected by such
    underreporting in our study, but underreporting may apply to other
    services to a lesser extent. On the other hand, our rates may be overstated
    because our cohort consists of Medicare beneficiaries with a known
    diagnosis of diabetes who used diabetes-related services in 1992, 1993, and
    1994. These individuals had relatively strong ties to the health care system
    and were perhaps more likely than the average beneficiary to be referred

     We relied primarily on ADA recommendations because our review of the literature and contacts with
    medical professional societies and diabetes experts indicated that ADA’s guidelines are the most
    widely accepted. We defined the six services using the 1996 HCFA Common Procedure Coding System,
    which is a modified version of the American Medical Association’s Physicians’ Current Procedural

    Page 28                                               GAO/HEHS-97-48 Medicare Diabetes Care
                              Appendix I
                              Methodology for Determining Use of
                              Recommended Diabetes Services in
                              Fee-for-Service Medicare

                              to and follow up on recommended services. Nonetheless, these potential
                              biases are not great enough to invalidate our findings.

                              In interpreting our results, it should be noted that (1) service utilization
                              rates are not adjusted to reflect differences in the severity of diabetes or
                              the extent of comorbidities among cohort members; (2) physicians and
                              diabetes experts may disagree about optimal frequencies for some
                              monitoring services in some patients because research evidence may be
                              inconclusive and individual patients vary in age, comorbidities, and other
                              factors; and (3) performing monitoring services as recommended does not
                              ensure improved health outcomes. Some studies have shown, for example,
                              that increased frequency of glycohemoglobin testing has not been
                              associated with improved blood glucose values.

Table I.1: Diabetes Cohort
Demographic Characteristics   Characteristic                                        Number           Percent
                              Total diabetes cohort                                  168,255           100.0
                              Under 65                                                15,170              9.0
                              65-69                                                   39,243            23.3
                              70-74                                                   44,600            26.5
                              75-79                                                   34,205            20.3
                              80-84                                                   21,467            12.8
                              85 and older                                            13,570              8.1
                              White                                                  134,512            80.0
                              Black                                                   21,272            12.6
                              Other                                                    6,742              4.0
                              Unknown                                                  5,729              3.4
                              Male                                                    68,799            40.9
                              Female                                                  99,456            59.1
                              Medicare eligibility category
                              Aged                                                   152,200            90.5
                              Disabled                                                16,055              9.5

                              Page 29                                   GAO/HEHS-97-48 Medicare Diabetes Care
                                           Appendix I
                                           Methodology for Determining Use of
                                           Recommended Diabetes Services in
                                           Fee-for-Service Medicare

Table I.2: Overall Utilization Rates for
Recommended Services                       Service and frequency                                               Number              Percent
                                           Physician visits, two or more per year                               157,338               93.5
                                           Eye exam, one or more per year                                        70,475               41.9
                                               Two or more per year                                              35,074               20.9
                                               One or more per year                                              63,980               38.0
                                           Urinalysis, one or more per year                                      89,365               53.1
                                           Serum cholesterol, one or more per year                              117,326               69.7
                                           Flu shot, one per fall season                                         74,214               44.1
                                            The flu shot may be underreported in Medicare claims because people may obtain it in
                                           nonmedical settings.

Table I.3: Utilization Rates for
Recommended Services, by Age               Service and frequency                  All ages       Under 65          65 to 74 75 and older
Group                                      Physician visits, two or more per
                                           year                                        93.5            90.1            93.3           94.6
                                           Eye exam, one or more per year              41.9            27.9            42.5           44.2
                                               Two or more per year                    20.9            19.1            23.1           18.5
                                               One or more per year                    38.0            36.5            41.0           34.8
                                           Urinalysis, one per year                    53.1            49.5            52.5           54.6
                                           Serum cholesterol, one per year             69.7            64.6            70.7           69.7
                                           Flu shot, one per fall season               44.1            30.4            46.3           44.4
                                            The flu shot may be underreported in Medicare claims because people may obtain it in
                                           nonmedical settings

                                           Page 30                                              GAO/HEHS-97-48 Medicare Diabetes Care
                                   Appendix I
                                   Methodology for Determining Use of
                                   Recommended Diabetes Services in
                                   Fee-for-Service Medicare

Table I.4: Utilization Rates for
Recommended Services, by Race      Service and frequency                  Total       White         Black        Other Unknown
                                   Physician visits, two or more
                                   per year                                 93.5        93.9           91.9       91.8       92.8
                                   Eye exam, one or more per
                                   year                                     41.9        43.1           36.1       37.2       41.4
                                       Two or more per year                 20.9        21.7           15.5       20.1       21.7
                                       One or more per year                 38.0        39.2           30.7       37.0       38.5
                                   Urinalysis, one per year                 53.1        53.3           52.0       53.5       52.7
                                   Serum cholesterol, one per
                                   year                                     69.7        70.7           64.2       69.3       68.9
                                   Flu shot, one per fall seasona           44.1        47.1           28.0       35.8       43.6
                                    The flu shot may be underreported in Medicare claims because people may obtain it in
                                   nonmedical settings.

Table I.5: Utilization Rates for
Recommended Services, by Sex       Service and frequency                                       Total          Male         Female
                                   Physician visits, two or more per year                      93.5            92.0          94.5
                                   Eye exam, one or more per year                              41.9            39.5          43.6
                                       Two or more per year                                    20.9            21.3          20.5
                                       One or more per year                                    38.0            38.7          37.5
                                   Urinalysis, one per year                                    53.1            53.0          53.2
                                   Serum cholesterol, one per year                             69.7            68.7          70.4
                                   Flu shot, one per fall season                               44.1            46.6          42.4
                                    The flu shot may be underreported in Medicare claims because people may obtain it in
                                   nonmedical settings.

                                   Page 31                                              GAO/HEHS-97-48 Medicare Diabetes Care
                                        Appendix I
                                        Methodology for Determining Use of
                                        Recommended Diabetes Services in
                                        Fee-for-Service Medicare

Table I.6: Combined Utilization Rates
for Four Key Services, by Diabetes                                                                  Percent                   Percent
Cohort Demographic Characteristics      Characteristic                                       receiving none               receiving all
                                        Total diabetes cohort                                            11.9                      10.8
                                        Under 65                                                         18.6                       7.7
                                        65-69                                                            12.5                      11.4
                                        70-74                                                            11.0                      12.1
                                        75-79                                                            10.1                      11.5
                                        80-84                                                            10.9                      10.2
                                        85 and older                                                     12.3                       6.9
                                        White                                                            11.2                      11.3
                                        Black                                                            15.5                       7.7
                                        Other                                                            14.7                      10.0
                                        Unknown                                                          12.3                      10.4
                                        Male                                                             13.4                      10.7
                                        Female                                                           10.9                      10.8
                                        Medicare eligibility category
                                        Aged                                                             11.2                      11.7
                                        Disabled                                                         18.5                       7.7
                                        Note: The combined recommended service indicator includes each of the following services
                                        annually: eye exam, one glycohemoglobin test, urinalysis, and serum cholesterol test.

                                        Page 32                                             GAO/HEHS-97-48 Medicare Diabetes Care
                                          Appendix I
                                          Methodology for Determining Use of
                                          Recommended Diabetes Services in
                                          Fee-for-Service Medicare

Table I.7: Utilization Rates for Recommended Services, by State
                     Number of                            Percent receiving recommended services
                      cohort   Four key Physician           Eye Glycohemoglobin
State              diabetics   services     visits         exam           (two)       Urinalysis    Cholesterol      Flu shot
Alabama                3,595        5.5       92.4          32.4               12.7        56.4             64.8         43.8
Alaska                  106        12.3       93.4          35.9               32.1        57.6             75.5         52.8
Arizona                1,531       16.0       91.9          41.6               28.4        56.7             80.5         51.8
Arkansas               2,014        7.1       92.8          46.5               10.9        50.8             54.5         51.3
California            10,806       12.3       94.4          43.3               21.3        56.3             74.2         36.9
Colorado               1,102       14.0       91.5          41.1               29.1        52.3             67.2         47.3
Connecticut            2,480       14.6       95.0          47.2               25.2        60.1             67.8         47.1
Delaware                548        10.8       94.2          45.8               18.4        44.0             68.8         44.5
District of
Columbia                474        13.3       93.9          43.0               19.8        51.9             76.6         28.7
Florida               10,872       17.5       95.4          52.3               25.1        63.8             81.0         46.3
Georgia                4,781        7.5       93.4          34.4               14.8        55.5             67.1         36.1
Hawaii                  580         8.8       96.6          35.9               20.3        54.0             76.2         46.7
Idaho                   512        11.1       91.4          35.9               29.3        51.0             72.9         56.8
Illinois               7,618        9.0       92.1          39.9               18.7        47.3             68.2         39.4
Indiana                4,205        6.8       93.8          37.8               17.8        43.5             62.0         50.5
Iowa                   1,962       12.2       93.2          46.7               23.1        51.3             65.4         52.8
Kansas                 1,604       12.7       92.0          48.4               28.0        53.2             69.3         50.3
Kentucky               2,969        6.7       93.9          35.4               14.1        51.9             65.6         43.1
Louisiana              3,421        7.3       92.5          43.6               11.3        53.1             67.1         33.7
Maine                   977        12.8       93.2          46.4               24.3        46.5             70.7         51.9
Maryland               3,163       12.3       93.7          43.0               25.1        48.9             70.6         44.0
Massachusetts          4,283       14.8       95.0          53.1               27.6        54.3             68.0         27.3
Michigan               7,770       11.3       93.9          38.3               24.0        57.8             71.2         47.3
Minnesota              1,937       10.7       91.5          41.2               28.4        51.7             58.9         48.8
Mississippi            2,398        4.7       90.4          36.0                9.3        57.0             61.8         39.9
Missouri               3,848        9.6       94.3          39.0               23.7        48.8             65.4         45.5
Montana                 448         8.5       90.2          45.1               15.4        51.1             62.1         54.0
Nebraska               1,015       10.5       91.3          53.9               18.4        49.1             61.6         55.9
Nevada                  520        12.3       90.4          35.2               24.8        56.2             75.0         42.9
New Hampshire           730         9.9       93.7          45.9               26.9        46.7             65.8         43.6
New Jersey             6,087       12.3       93.8          43.1               24.5        48.0             78.0         41.2
New Mexico              699        10.6       89.7          36.5               22.6        49.6             65.4         29.8
New York              12,175       16.2       93.9          50.9               24.9        56.5             75.0         41.6
North Carolina         5,412        8.5       92.9          41.0               15.3        54.6             66.4         42.4

                                          Page 33                                     GAO/HEHS-97-48 Medicare Diabetes Care
                                         Appendix I
                                         Methodology for Determining Use of
                                         Recommended Diabetes Services in
                                         Fee-for-Service Medicare

                 Number of                                Percent receiving recommended services
                     cohort   Four key Physician             Eye Glycohemoglobin
State             diabetics   services     visits           exam           (two)              Urinalysis        Cholesterol      Flu shot
North Dakota           400        11.5        89.8            46.0                   23.8            57.3                67.8          51.8
Ohio                 9,455         8.2        94.7            40.3                   17.2            49.4                66.6          49.8
Oklahoma             2,090         8.3        91.7            34.9                   17.6            51.8                68.9          43.5
Oregon               1,243        10.8        92.5            32.9                   27.5            49.6                76.5          53.3
Pennsylvania        11,794         7.9        95.6            37.7                   22.1            46.1                69.4          49.1
Rhode Island           801        12.6        95.1            47.9                   23.2            58.4                58.1          43.1
South Carolina       2,947         6.5        92.9            37.5                   10.4            53.7                60.4          42.6
South Dakota           444        10.8        88.1            40.1                   21.4            55.9                64.0          50.0
Tennessee            3,964         7.4        93.0            32.8                   16.7            55.4                65.4          48.1
Texas                9,483        10.8        91.4            41.6                   18.4            56.0                72.4          40.3
Utah                   663         9.2        88.4            38.5                   22.3            47.1                67.1          47.4
Vermont                374         8.3        94.1            35.3                   24.1            40.6                59.9          42.8
Virginia             4,270        10.4        93.3            40.1                   21.3            54.0                68.1          49.3
Washington           2,299        14.8        92.2            43.2                   28.9            52.2                75.7          50.3
West Virginia        1,756         6.4        92.9            35.7                   14.1            47.6                64.8          40.7
Wisconsin            3,445         9.6        93.4            38.0                   27.0            48.9                64.4          52.6
Wyoming                185         7.0        89.2            36.8                   18.4            41.6                67.0          40.5
United States      168,255        10.8        93.5            41.9                   20.9            53.1                69.7          44.1

                                         Note: The four key services in the combined recommended service indicator (at least one per
                                         year) include eye exam, one glycohemoglobin test, urinalysis, and serum cholesterol test.

                                         Page 34                                               GAO/HEHS-97-48 Medicare Diabetes Care
Appendix II

Methodology for Determining Use of
Diabetes Management Approaches by
Medicare HMOs
              This appendix discusses our examination of diabetes management efforts
              by Medicare HMOs. It briefly describes our methodology and the key
              findings from our survey.

              To better understand the approaches to diabetes management used by
Methodology   HMOs, we conducted a telephone survey of nearly half of the current
              Medicare risk-contract plans. We selected plans that had (1) enrollment of
              at least 1,000 Medicare beneficiaries (as of April 1996) and (2) a contract
              effective date no later than December 31, 1993. By using minimum
              enrollment and participation date as selection criteria, we could eliminate
              plans with so few Medicare enrollees that their population of enrollees
              with diabetes might be too small to warrant special diabetes management
              efforts and plans new to Medicare that might not be fully familiar with the
              special needs of Medicare enrollees. Of the 201 Medicare risk-contract
              HMOs operating in April 1996,26 90 plans met these criteria, and we
              interviewed representatives of 88 of the plans (2 plans did not participate).
              Data on plan characteristics were obtained from HCFA reports and officials
              (see table II.1).

               HCFA, Monthly Report of Medicare Managed Care Plans (Washington, D.C.: Apr. 1996),
              http://www.hcfa.gov/stats/monthly.htm (cited Apr. 12, 1996).

              Page 35                                              GAO/HEHS-97-48 Medicare Diabetes Care
                                     Appendix II
                                     Methodology for Determining Use of
                                     Diabetes Management Approaches by
                                     Medicare HMOs

Table II.1: Characteristics of HMO
Plans in Our Survey                                                                                      Number of
                                     Descriptive variable                                                   plans
                                     Model type
                                     Staff                                                                       13
                                     Group                                                                       15
                                     Independent practice association                                            60
                                     Tax status
                                     For profit                                                                  54
                                     Not for profit                                                              34
                                     Medicare contract experience
                                     Less than 5 years                                                           28
                                     5-10 years                                                                  45
                                     More than 10 years                                                          15
                                     Medicare enrollment
                                     10,000 or less                                                              24
                                     10,001-20,000                                                               27
                                     20,001-50,000                                                               25
                                     More than 50,000                                                            12
                                     Northeast                                                                   17
                                     Southeast                                                                   11
                                     Midwest                                                                      9
                                     Central                                                                     19
                                     West Coast                                                                  32

                                     The telephone survey, consisting of 23 multiple-choice and open-ended
                                     questions, was designed to determine each HMO’s specific approaches to
                                     diabetes management. The questions addressed interventions targeted to
                                     plan enrollees and physicians, as well as plan-level activities, such as the
                                     HMO’s ability to identify its enrollees with diabetes and monitor utilization
                                     rates of recommended services. To administer the survey, we interviewed
                                     the individual identified by the plan as being most familiar with plan
                                     approaches to diabetes management. In most cases, the respondent was
                                     the plan’s medical director; in other cases, it was a physician from the
                                     plan’s endocrinology department or a representative of the plan’s wellness
                                     or quality improvement department. We did not attempt to independently
                                     verify the responses to our questions.

                                     Page 36                                   GAO/HEHS-97-48 Medicare Diabetes Care
                                        Appendix II
                                        Methodology for Determining Use of
                                        Diabetes Management Approaches by
                                        Medicare HMOs

                                        The 88 HMOs reported a wide range of diabetes management efforts,
Survey Results                          encompassing more than 30 different initiatives. Their efforts
                                        predominantly focused on educating patients about self-management and
                                        providers about recommended services. Many of the HMOs used similar
                                        strategies for improving care. (See table II.2.)

Table II.2: HMO Responses to Selected
Survey Questions                                                                                                                Number of
                                        Survey question                                                                             “yes”
                                        Does your plan occasionally include information about diabetes in regular
                                        newsletters mailed to all enrollees?                                                                82
                                        Does your plan provide (diabetes-related) information to physicians through
                                        newsletters or mailings to physicians?                                                              71
                                        Does your plan have health professionals, such as diabetes educators,
                                        nutritionists, or diabetes nurses, available for enrollee education?                                68
                                        Does your plan have any policies or procedures that are used to guide
                                        physicians’ treatment of diabetic enrollees, such as guidelines, practice
                                        parameters, or information briefs?                                                                  62
                                        Does your plan maintain a list or registry of your enrollees with type II
                                        diabetes?                                                                                           61a
                                        Does your plan use case managers to monitor the medical care that your
                                        diabetic enrollees receive?                                                                         60
                                        Has your plan set performance goals for diabetes care?                                              58
                                        Does your plan mail educational newsletters or pamphlets about diabetes
                                        care to your diabetics?                                                                             41
                                        Does your plan operate any type of program designed to consolidate
                                        services for diabetics?                                                                             31
                                        Does your plan have a computer system that generates reminders for
                                        physicians when specific patients are due for specific services?                                    24
                                        Can you estimate about what proportion of all your Medicare enrollees have
                                        type II diabetes?                                                                                   20
                                         Many of the HMOs that responded “yes” to this question do not actively maintain or use their
                                        registry information about enrollees with diabetes. Many plans explained that their registry is
                                        updated annually as they identify their enrollees with diabetes for the Health Plan Employer Data
                                        and Information Set.

                                        In general, we did not find a strong association between the use of
                                        particular approaches to diabetes management and specific HMO
                                        characteristics, such as model type, tax status (for profit or not for profit),
                                        or size. (See tables II.3 and II.4.) However, for-profit HMOs reported slightly
                                        higher use of several diabetes management approaches than not-for-profit
                                        HMOs. These included use of diabetes registries, mailings to enrollees with

                                        Page 37                                                GAO/HEHS-97-48 Medicare Diabetes Care
                                          Appendix II
                                          Methodology for Determining Use of
                                          Diabetes Management Approaches by
                                          Medicare HMOs

                                          diabetes, and employment of diabetes-related health professionals, such as
                                          certified diabetes educators or nutritionists. Similarly, HMOs with the most
                                          experience as Medicare contractors—either in Medicare enrollment or in
                                          length of Medicare contract—were more likely to use certain diabetes
                                          management approaches, such as clinical practice guidelines, mailings to
                                          physicians and enrollees, and a diabetes registry.

Table II.3: Diabetes Interventions Reported by HMOs (Percent)
                                     Clinical    Mailings to
                                    practice enrollees with   Allied health                      Case           Mailings to        Diabetes
Descriptive variable              guidelines       diabetes professionalsa                 management           physicians          registry
Model type
Staff                                  92                      46                   85                  77               69              69
Group                                  80                      33                   87                  53               80              73
Independent practice
association                            63                      50                   73                  70               83              68
Tax status
For profit                             82                      56                   83                  69               94              78
Not for profit                         53                      32                   68                  68               59              56
Medicare contract experience
Less than 5 years                      54                      50                   64                  68               79              57
5-10 years                             73                      53                   82                  71               82              80
More than 10 years                     93                      20                   87                  60               80              60
Medicare enrollment
10,000 or less                         46                      38                   75                  67               71              54
10,001-20,000                          70                      48                   82                  82               78              70
20,001-50,000                          84                      44                   76                  52               84              72
More than 50,000                       92                      67                   75                  75              100              92
Northeast                              94                      59                   88                  65               77              65
Southeast                              55                      27                   36                  82               46              36
Midwest                                78                      22                   78                  44               56              67
Central                                74                      47                   79                  79               95              79
West Coast                             59                      53                   84                  66               94              78
                                              Such as certified diabetes educators or nutritionists.

                                          Page 38                                                      GAO/HEHS-97-48 Medicare Diabetes Care
                                        Appendix II
                                        Methodology for Determining Use of
                                        Diabetes Management Approaches by
                                        Medicare HMOs

Table II.4: HMOs Efforts to Monitor Recommended Services by Plan Characteristic (Percent)
Descriptive variable              Eye exam   Glycohemoglobin         Urinalysis Cholesterol     Flu shot     Foot exams
Model type
Staff                                 55                    46               55         46            46              36
Group                                 92                    69               54         46            62              31
Independent practice
association                           95                    60               55         50            45              36
Tax status
For profit                            87                    59               56         54            49              41
Not for profit                        89                    59               52         41            48              26
Medicare contract experience
Less than 5 years                     86                    71               71         48            52              43
5-10 years                            97                    58               52         55            46              33
More than 10 years                    67                    42               33         33            50              25
Medicare enrollment
10,000 or less                        86                    50               50         43            43              36
10,001-20,000                         91                    67               67         67            57              38
20,001-50,000                         91                    52               38         33            38              29
More than 50,000                      80                    70               70         50            60              40
Northeast                             85                    85               77         77            62              39
Southeast                             50                    25               50         50            50              25
Midwest                               71                    29               14         14            43               0
Central                               93                    64               50         43            43              50
West Coast                            96                    57               57         46            46              36

                                        Page 39                                     GAO/HEHS-97-48 Medicare Diabetes Care
Appendix III

Comments From the Health Care Financing

               Page 40       GAO/HEHS-97-48 Medicare Diabetes Care
Appendix III
Comments From the Health Care Financing

Page 41                                   GAO/HEHS-97-48 Medicare Diabetes Care
Appendix IV

Major Contributors to This Report

               Rosamond Katz, Assistant Director, (202) 512-7148
               Ellen M. Smith, Evaluator-in-Charge
               Jennifer Grover, Evaluator
               Stan Stenersen, Evaluator
               Evan Stoll, Programmer Analyst

(108255)       Page 42                                 GAO/HEHS-97-48 Medicare Diabetes Care
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