How Does the Health Care Plan Approach Managing Diabetes?

How often does the health care plan revise its guidelines for diabetes treatment, and does the plan base these guidelines on the American Diabetes Association (ADA) standards of care?

Plans that regularly revise treatment guidelines (at least every 2 years), as a result of revisions made by the American Diabetes Association (ADA), closely follow the advances in diabetes care for their health plan members. This means that their members and health care providers will have the most up-to-date treatment and education available, to help them achieve the best diabetes control possible. This knowledge should translate to high-quality clinical management. To determine whether your health plan regularly revises guidelines, contact the plan’s customer service rep or ask if they have a diabetes case manager. The American Diabetes Association also offers standards of care and a list of practitioners who have completed the ADA’s approval process.

What are the Health Plan Employer Data and Information Set diabetes-relevant scores for the plan?

The Health Plan Employer Data and Information Set (HEDIS) is an annual data set that rates health plan services. Its data allow comparison of different health plans services. HEDIS data can tell you:

• If current members are satisfied with the plan;
• The percentage of members and doctors who have recently left the plan;
• The plan’s record on preventive care, such as how many eligible members with diabetes have yearly eye exams, cholesterol and triglyceride tests, and regular A1C tests*; and
• The plan’s ability to treat chronic conditions such as diabetes and hypertension.

HEDIS data include an evaluation of a health plans comprehensive clinical management of patients with diabetes, and evaluate the following aspects of diabetes care:

• What percent of the plan's members with diabetes have annual A1C tests?
• What percent of the plan's members with diabetes have an A1C value greater than 7 percent? (An A1C test shows the percentage of glucose that is attached to the red blood cell. The red cell lasts 90 to 120 days, so the test can measure blood sugar control over time. The American Diabetes Association recommends that A1C tests not exceed 7 percent.)
• What percent of the plan's members with diabetes have their lipids monitored yearly?
• What percent of the plan's members with diabetes have a LDL cholesterol level that is less than 100 mg/dl?
• What percent of the plan's members with diabetes have a dilated eye (retinal) examination biennially if they have had no previous problems and yearly if they are at risk?
• What percent of the plan's members with diabetes are monitored for nephropathy every year?

The National Committee for Quality Assurance (NCQA) analyzes the HEDIS data submitted by health plans including health maintenance organizations (HMOs) and preferred provider organizations (PPOs), and publishes the Quality Compass Values. These values measure the performance of each health plan’s efforts to help patients manage a variety of health issues including their diabetes by assessing patient screenings (which might include eye exams, monitoring flu shots or foot exams) and levels of A1C and lipid control. Over the years, the number of health plans reporting such information has increased, and thus provided consumers with more information about which health plans are better helping patients to manage their diabetes. Quality Compass Values can only be purchased from NCQA. Fees vary based on volume.

Following are the 2001 Quality Compass (QC) health plan scores falling at the 75th percentile (did better than 25 percent of all who submitted information or data) or better. When assessing your current or a potential health plan’s scores you may want to use this chart as a comparison guide.

 

HEDIS MEASURE	Percentage of Patients Meeting the Measure
Diabetes, A1C screening	85.29
Diabetes, poor A1C control	25.55
Diabetes, lipid screening	82.48
Diabetes, lipid control	50.85
Diabetes, eye exams*	58.15
Diabetes, monitoring nephropathy	49.09

*Percentage of population with diabetes that has had an eye exam in the past year or in the past two years if any two of the following conditions are met:

1. The patient is not taking insulin
2. The patient has an A1C less than 8.0%
3. The patient had no evidence of retinopathy on the previous eye exam.

Plans with excellent HEDIS scores have been successful in their efforts to implement effective diabetes programs and services for their members. For five of the six diabetes HEDIS measures, a higher score is better than a lower score: only for poor A1C control is a lower score better than a higher score.