Medicare: Provision of Key Preventive Diabetes Services Falls Short of Recommended Levels

Published by the Government Accountability Office on 1997-04-11.

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

                          United States General Accounting Office

GAO                       Testimony
                          Before the Subcommittee on Health and Environment,
                          Committee on Commerce, House of Representatives

For Release on Delivery
Expected at 9:30 a.m.
Friday, April 11, 1997

                          Provision of Key Preventive
                          Diabetes Services Falls
                          Short of Recommended
                          Statement of Bernice Steinhardt, Director
                          Health Services Quality and Public Health Issues
                          Health, Education, and Human Services Division

Medicare: Provision of Key Preventive
Diabetes Services Falls Short of
Recommended Levels
               Mr. Chairman and Members of the Subcommittee:

               We are pleased to be here today to discuss our recent report on preventive
               and monitoring services provided to Medicare beneficiaries with diabetes.1
                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—including both appropriate medical management and patient
               self-management—can improve the quality of life for people with diabetes,
               and it may help control costs. 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.

               The Medicare Preventive Benefit Improvement Act of 1997 (H.R. 15,
               introduced Jan. 7, 1997) proposes new Medicare coverage for a number of
               preventive services, including diabetes outpatient self-management
               training, and for blood-testing strips that people with diabetes use to
               monitor their blood glucose control. While we did not specifically assess
               these proposals, our findings on the use of diabetes preventive and
               monitoring services should contribute to deliberations on this legislation.

               At your request, we examined 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 Medicare health maintenance
               organizations (HMO) doing to improve delivery of recommended diabetes
               services? (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. We also surveyed 88 HMO plans serving Medicare
               beneficiaries on their approaches to preventive diabetes care and
               conducted follow-up interviews with 12 of those plans.

               In brief, we found that while experts agree that regular use of preventive
               and monitoring services can help minimize the complications of diabetes,
               most Medicare beneficiaries with diabetes do not receive these services at

                Medicare: Most Beneficiaries With Diabetes Do Not Receive Recommended Monitoring Services
               (GAO/HEHS-97-48, Mar. 28, 1997).

               Page 1                                                                    GAO/T-HEHS-97-113
                     Medicare: Provision of Key Preventive
                     Diabetes Services Falls Short of
                     Recommended Levels

                     recommended intervals. This is true both in traditional fee-for-service
                     Medicare, which serves about 90 percent of all beneficiaries, and in
                     managed care delivery. The efforts of Medicare HMOs to improve diabetes
                     care have been varied but generally limited, with most plans reporting that
                     they have focused on educating their enrollees with diabetes about
                     self-management and their physicians about the need for preventive and
                     monitoring services. Very few plans have developed comprehensive
                     diabetes management programs. At the federal level, HCFA has targeted
                     diabetes for special emphasis and has begun to test preventive care
                     initiatives; but like the HMOs, HCFA’s efforts are quite recent and the agency
                     does not yet have results that would allow it to evaluate effectiveness.

                     The American Diabetes Association’s (ADA) clinical care
Medicare             recommendations, which reflect the published research evidence and
Beneficiaries With   expert opinion, are widely accepted as guidance on what constitutes
Diabetes Are Not     quality diabetes care. We selected for review six of ADA’s recommended
                     monitoring services that can be measured using Medicare claims data (see
Receiving            table 1). The service frequencies recommended in table 1 generally apply
Recommended Levels   to the average person with noninsulin-dependent diabetes, the type that
                     accounts for more than 90 percent of diabetics in Medicare. Of course,
of Monitoring        some individuals may need more or fewer services depending on their age,
Services             medical condition, whether they use insulin, or how well their blood sugar
                     is controlled.

                     Page 2                                                       GAO/T-HEHS-97-113
                                        Medicare: Provision of Key Preventive
                                        Diabetes Services Falls Short of
                                        Recommended Levels

Table 1: Diabetes Monitoring Services
Included in Our Analysis                                                Frequency per
                                        Service                                  year           Purpose
                                        Physician visits                                        Monitor general health and diabetes
                                                                                                control; order and review lab tests;
                                                                                                conduct foot exams; and refer to other
                                                                                     2-4        services
                                        Eye exam (dilated)                                      Identify early signs of diabetic
                                                                                        1       retinopathy and refer for treatment
                                        Glycohemoglobin test                                    Assess and monitor achievement of
                                                                                        2       glycemic control goals
                                        Urinalysis test                                         Monitor kidney function by testing for
                                                                                        1       albumin or protein
                                        Serum cholesterol test                                  Monitor cholesterol as contributor to
                                                                                        1       heart disease and circulatory problems
                                        Flu shot (in season)                                    General preventive service for
                                                                                                high-risk populations, such as older
                                                                                        1       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).

                                        As figure 1 shows, our cohort of about 168,000 Medicare beneficiaries with
                                        diabetes in fee-for-service delivery fell far short of the recommended
                                        frequencies of most monitoring services in 1994. Although 94 percent of
                                        the beneficiaries received at least two physician visits, less than half
                                        (42 percent) received an eye exam, only 21 percent received the
                                        recommended two glycohemoglobin tests, and 53 percent had a urinalysis.
                                        The fact that 70 percent received a serum cholesterol test may reflect both
                                        the successful public education campaign in the late 1980s and the
                                        frequent inclusion of cholesterol in automated blood tests. We believe the
                                        flu shot (44 percent) is underreported in Medicare claims data, because
                                        many people receive flu shots in nonmedical settings.

                                        Page 3                                                                       GAO/T-HEHS-97-113
                                        Medicare: Provision of Key Preventive
                                        Diabetes Services Falls Short of
                                        Recommended Levels

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






















                                        Recommended Monitoring Services

                                        Utilization rates are even lower when the monitoring services are
                                        considered as a unit. (See fig. 2.) About 12 percent of our diabetes cohort
                                        did not receive any of four key monitoring services: at least one each of
                                        the eye exam, glycohemoglobin test, urinalysis, and serum cholesterol test.
                                        About 11 percent showed Medicare claims for all four of these services.

                                        Page 4                                                                        GAO/T-HEHS-97-113
                                          Medicare: Provision of Key Preventive
                                          Diabetes Services Falls Short of
                                          Recommended Levels

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





                                           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.

                                          We analyzed utilization rates by patient characteristics and found that
                                          rates were generally similar for men and women and for all age groups
                                          over age 65. However, only 28 percent of beneficiaries under age 65 (who
                                          were eligible for Medicare because of disability) received an eye exam,
                                          compared with 43 percent of those aged 65 to 74 and 44 percent of those
                                          75 and older. We also found that white beneficiaries with diabetes
                                          received the six monitoring services at consistently higher rates than
                                          beneficiaries who were black or of another racial group, but the
                                          differences were not great.

                                          We were unable to conduct a similar analysis of the six monitoring
                                          services’ use rates among beneficiaries with diabetes who were enrolled in
                                          Medicare HMOs because HCFA does not require its HMO contractors to report
                                          patient-specific utilization data. According to the limited data we obtained
                                          from published research and other sources, however, it appears that use
                                          rates are also below recommended levels in Medicare HMOs.

                                          Page 5                                                                      GAO/T-HEHS-97-113
                         Medicare: Provision of Key Preventive
                         Diabetes Services Falls Short of
                         Recommended Levels

Patient and Physician    Although it is unclear what specifically accounts for the
Factors Contribute to    less-than-recommended use of monitoring services found in our study, a
Less-Than-Recommended    number of factors—including patient and physician attitudes and
                         practices—may contribute to the situation. Some experts expressed
Utilization              concern that both patients and physicians need to take diabetes more
                         seriously and make the effort to manage it more aggressively.

                         Patients with a chronic condition such as diabetes bear much of the
                         responsibility for successful disease management; but for many patients,
                         self-management does not become a priority until serious complications
                         develop. Then, difficult lifestyle changes may be required, such as weight
                         loss, smoking cessation, and increased exercise. Patients may lack the
                         knowledge, motivation, and adequate support systems to make these
                         changes in addition to undertaking the active self-monitoring and
                         preventive service regimens that are necessary to control diabetes.

                         The substantial out-of-pocket costs of active self-management also may
                         discourage Medicare beneficiaries with diabetes. Diabetes-related supplies
                         that are used at home, such as insulin, syringes, and blood glucose-testing
                         strips, are not fully covered by Medicare. For example, insulin costs about
                         $40 to $70 for a 90-day supply, syringes cost $10 to $15 per 100, and
                         glucose-testing strips cost 50 to 72 cents each (or about $1,000 a year for a
                         diabetic who tests four times a day).

                         Another factor in the underutilization of recommended preventive and
                         monitoring services may be physicians and other health care providers
                         who are not familiar with the latest diabetes guidelines and research
                         supporting the efficacy of treatment. Moreover, many Medicare
                         beneficiaries with diabetes have several serious medical conditions, and in
                         the limited time of a patient visit, a physician is likely to focus on the
                         patient’s most urgent concerns, perhaps neglecting ongoing diabetes
                         management and patient education. Finally, managed care plans and
                         physician practices alike tend to lack service-tracking systems capable of
                         reminding physicians and patients when routine preventive and
                         monitoring services are needed.

                         We surveyed 88 Medicare HMO contractors about their efforts to manage
HMO Efforts to           diabetes care, with particular attention to how they encouraged the use of
Manage Diabetes Care     preventive and monitoring services. We expected that the HMOs might have
Are Varied but Limited   identified diabetes as a problem area and might have taken steps to
                         implement management approaches. These HMOs did in fact report a wide

                         Page 6                                                      GAO/T-HEHS-97-113
                        Medicare: Provision of Key Preventive
                        Diabetes Services Falls Short of
                        Recommended Levels

                        range of diabetes management efforts, and a few were developing
                        comprehensive programs; but most plans’ efforts were limited primarily to
                        educational approaches. Most efforts were initiated recently, and little is
                        known yet about their effectiveness.

                        Every HMO in our survey reported using at least one approach to educate
                        enrollees with diabetes about appropriate diabetes management. The most
                        common approach—used by 82 of the 88 plans—was featuring articles
                        about diabetes in publications for all enrollees. In addition, some plans
                        provided comprehensive manuals to their diabetic enrollees. Sixty-eight
                        HMOs reported having diabetes-related health professionals, such as
                        nurses, certified diabetes educators, and nutritionists available to educate
                        enrollees. A number of plans offered classes for several levels of diabetes
                        education ranging from basic to advanced. Ten plans contracted with
                        disease management companies to provide diabetes education services,
                        and a few reported telephone advice services.

                        Most of the HMOs reported they also had undertaken educational efforts
                        directed to their physicians, stressing the importance of preventive care
                        through such means as written materials and meetings. Nearly
                        three-fourths of the HMOs reported using clinical practice guidelines for
                        diabetes care. In one HMO, 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. This plan also
                        has developed a physician training video on diabetic foot care.

Many Plans Are          Although information and education may produce short-term behavioral
Augmenting Education    changes, they may not be enough to sustain the long-term behavioral and
With Other Approaches   lifestyle changes necessary to achieve good diabetes control. Recognizing
                        this, many of the HMOs in our survey reported using additional approaches
                        to continuously encourage appropriate diabetes management. For
                        example, about half of the HMOs reported one or more types of reminders
                        for enrollees and physicians, such as wallet-sized scorecards for enrollees
                        to chart receipt of recommended services and posters in examining rooms
                        reminding patients to take off their shoes and socks to prompt physicians
                        to check their feet. As another example, 52 of the 62 plans that used
                        clinical practice guidelines for diabetes reported having a system to
                        monitor physicians’ compliance with the guidelines and, in some cases, to
                        provide feedback to the physicians.

                        Page 7                                                     GAO/T-HEHS-97-113
                            Medicare: Provision of Key Preventive
                            Diabetes Services Falls Short of
                            Recommended Levels

                            In our follow-up interviews with 12 HMOs that reported using a variety of
                            diabetes services, 5 told us they have committed substantial resources to
                            develop systemwide, comprehensive diabetes management programs. For
                            example, one HMO has based its approach to diabetes management around
                            the long-term goals of improving patient health status and satisfaction as
                            well as on plan performance on cost and utilization. Through a variety of
                            interventions, such as diabetes care clinics, patient self-management
                            notebooks, and diabetes education by telephone, this HMO tries to improve
                            patient outcome measures ranging 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. Interventions designed to
                            help physicians provide better diabetes care include an online diabetes
                            registry updated monthly, use of evidence-based clinical practice
                            guidelines, outcomes reports for physicians, and training by diabetes
                            expert teams.

Little Evidence Available   Even the HMOs reporting the most comprehensive programs, however,
on Effectiveness of         generally had little information about the extent to which their diabetes
Diabetes Management         management approaches had affected the use of recommended preventive
                            and monitoring services. At best, they tended to collect utilization data on
Efforts                     five or fewer services, and they began collecting these data only in 1993 or
                            1994. The service monitored most frequently, by 58 of the plans, was the
                            diabetic eye exam. This was probably due to the eye exam’s inclusion in
                            HEDIS (the Health Plan Employer Data and Information Set), the
                            performance-reporting system for commercial HMOs.

                            Although little information exists on the relative effectiveness of specific
                            diabetes management approaches, experts generally believe that intensive
                            and sustained interventions, such as in-person counseling and education
                            rather than telephone calls or mailings, are most likely to support
                            long-term behavior change. Because intensive interventions probably are
                            more expensive than other approaches, it is important to measure their
                            effectiveness before committing resources to them.

                            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. Among these initiatives is the National Diabetes
                            Education Program, in which HCFA is participating with CDC and the
Effectiveness Is Still      National Institute of Diabetes and Digestive and Kidney Diseases. This
Largely Unknown             program is being designed to increase general public awareness of

                            Page 8                                                     GAO/T-HEHS-97-113
              Medicare: Provision of Key Preventive
              Diabetes Services Falls Short of
              Recommended Levels

              diabetes as well as patient and provider education about diabetes and
              practice guidelines.

              HCFA works with local peer review organizations (PRO), each of which
              currently is required to implement at least one diabetes-related quality
              improvement project involving the providers in its state or states. A total
              of 33 diabetes-related projects were under way in late 1996. Finally, HCFA is
              sponsoring a multistate evaluation of diabetes intervention strategies, the
              Ambulatory Care Diabetes Project, which involves fee-for-service and HMO
              providers and PROs in eight states. The project has completed its baseline
              data collection and intervention stages, and began remeasurement for
              outcomes analysis in January 1997.

              HCFA  also wants to encourage development of better data collection
              systems for improved service utilization tracking. The agency anticipates
              requiring its Medicare HMO contractors to report the new HEDIS 3.0
              performance measures, which include the diabetic eye exam and flu shot
              rates, and may add a measure of the glycohemoglobin test in the future.
              Moreover, HCFA is supporting research on other process- and
              outcomes-based performance measurement systems and is considering
              testing the feasibility of performance measurements in fee-for-service

              Like the diabetes management approaches we learned about in our survey
              of Medicare HMOs, HCFA’s initiatives either have been undertaken recently
              or are still in the planning stages, and it is too soon to tell which of these
              projects will prove most effective. At the same time, some diabetes
              specialists have suggested that HCFA should be doing more, such as
              studying the effects of easing current coverage limitations on diabetes
              self-management training and supplies like blood-testing strips.

              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. Conversely,
              following the recommendations may enhance beneficiaries’ quality of life.

              Effectively managing diabetes is difficult to accomplish, however, and
              requires long-term, concerted efforts by people with diabetes and their

              Page 9                                                       GAO/T-HEHS-97-113
               Medicare: Provision of Key Preventive
               Diabetes Services Falls Short of
               Recommended Levels

               physicians. Among HMOs, where coordinated care and prevention are
               expected to receive special emphasis, many plans are exploring ways to
               improve diabetes management; but providers may be reluctant to invest in
               expensive approaches until their cost-effectiveness is more evident. HCFA,
               also recognizing the importance of this issue, has initiated a promising
               strategy of testing a variety of approaches to learn what works best in
               Medicare—that is, what is effective and what can be implemented at
               reasonable cost.

               Mr. Chairman, this concludes my statement. I would be happy to answer
               any questions from you and other members of the Subcommittee. Thank

               This testimony was prepared under the direction of Bernice Steinhardt,
Contributors   Director, Health Services Quality and Public Health Issues, who may be
               reached at (202) 512-7119 if there are any questions. Other key
               contributors include Rosamond Katz, Assistant Director, and Ellen M.
               Smith, Jennifer Grover, Evan Stoll, and Stan Stenersen, Evaluators.

(108325)       Page 10                                                   GAO/T-HEHS-97-113
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