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

MEDICARE

Provision of Key Preventive

Diabetes Services Falls

Short of Recommended

Levels

Statement of Bernice Steinhardt, Director

Health Services Quality and Public Health Issues

Health, Education, and Human Services Division

GAO/T-HEHS-97-113

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

1

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.

Medicare

Beneficiaries With

Diabetes Are Not

Receiving

Recommended Levels

of Monitoring

Services

The American Diabetes Association’s (ADA) clinical care

recommendations, which reflect the published research evidence and

expert opinion, are widely accepted as guidance on what constitutes

quality diabetes care. We selected for review six of ADA’s recommended

monitoring services that can be measured using Medicare claims data (see

table 1). The service frequencies recommended in table 1 generally apply

to the average person with noninsulin-dependent diabetes, the type that

accounts for more than 90 percent of diabetics in Medicare. Of course,

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.

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

Service

Frequency per

year Purpose

Physician visits

2 - 4

Monitor general health and diabetes

control; order and review lab tests;

conduct foot exams; and refer to other

services

Eye exam (dilated)

1

Identify early signs of diabetic

retinopathy and refer for treatment

Glycohemoglobin test

2

Assess and monitor achievement of

glycemic control goals

Urinalysis test

1

Monitor kidney function by testing for

albumin or protein

Serum cholesterol test

1

Monitor cholesterol as contributor to

heart disease and circulatory problems

Flu shot (in season)

1

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).

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

Services, 1994

Percentage Receiving Service

0

10

20

30

40

50

60

70

80

90

100

Physician Visits

Eye Exam

Glycohemoglobin

Urinalysis

Cholesterol

Flu Shot

Recommended Monitoring Services

94

42

21

53

70

44

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,

1994

Percentage Receiving Services

0

10

20

30

40

50

60

70

80

90

100

01234

Number of Services Received

12

21

30

26

11

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

Factors Contribute to

Less-Than-Recommended

Utilization

Although it is unclear what specifically accounts for the

less-than-recommended use of monitoring services found in our study, a

number of factors—including patient and physician attitudes and

practices—may contribute to the situation. Some experts expressed

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.

HMO Efforts to

Manage Diabetes Care

Are Varied but Limited

We surveyed 88 Medicare HMO contractors about their efforts to manage

diabetes care, with particular attention to how they encouraged the use of

preventive and monitoring services. We expected that the HMOs might have

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

Augmenting Education

With Other Approaches

Although information and education may produce short-term behavioral

changes, they may not be enough to sustain the long-term behavioral and

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

on Effectiveness of

Diabetes Management

Efforts

Even the HMOs reporting the most comprehensive programs, however,

generally had little information about the extent to which their diabetes

management approaches had affected the use of recommended preventive

and monitoring services. At best, they tended to collect utilization data on

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 Targeted

Diabetes for Special

Initiatives, but

Effectiveness Is Still

Largely Unknown

HCFA has identified diabetes as a major health problem in the Medicare

population and has targeted the disease for special initiatives to improve

physician and patient awareness, service delivery, and, ultimately, patient

health outcomes. Among these initiatives is the National Diabetes

Education Program, in which HCFA is participating with CDC and the

National Institute of Diabetes and Digestive and Kidney Diseases. This

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

Medicare.

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.

Conclusions Diabetes care is a microcosm of the challenges facing the nation’s health

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

you.

Contributors This testimony was prepared under the direction of Bernice Steinhardt,

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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