Medicare: Most Beneficiaries With Diabetes Do Not Receive Recommended
Monitoring Services (Letter Report, 03/28/97, GAO/HEHS-97-48).

Pursuant to a congressional request, GAO reviewed how well the health
care system provides preventive services to Medicare beneficiaries with
diabetes, focusing on: (1) the extent to which Medicare beneficiaries
with diabetes receive recommended levels of preventive and monitoring
services; (2) what health maintenance organizations (HMO) that serve
Medicare beneficiaries are doing to improve delivery of recommended
diabetes services; and (3) what activities the Health Care Financing
Administration (HCFA) supports to address these service needs for
Medicare beneficiaries with diabetes.

GAO noted that: (1) although 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 recommended intervals; (2) more than 90 percent of
fee-for-service Medicare beneficiaries with diabetes visited their
physicians at least twice in 1994; (3) 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; (4) on the whole, these fee-for-service utilization rates did
not vary substantially by patient age, sex, or race; (5) the provision
of preventive and monitoring services under managed care is also below
recommended levels, although data for this service delivery approach are
limited; (6) 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; (7) 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; (8) Medicare HMO
efforts to improve diabetes care have been varied, but generally
limited; (9) 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; (10) 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; (11) because virtually all
of these efforts have begun within the past 3 years, little is known
about their effectiveness; (12) HCFA also has begun to test preventive
care initiatives for diabetes and has targeted this area for special
emphasis; (13) 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; (14) 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; and (15) to the extent that these initiat*

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-97-48
     TITLE:  Medicare: Most Beneficiaries With Diabetes Do Not Receive 
             Recommended Monitoring Services
      DATE:  03/28/97
   SUBJECT:  Health care programs
             Health maintenance organizations
             Health care services
             Diseases
             Health resources utilization
             Health services administration
             Monitoring
             Medical examinations
             Education or training
IDENTIFIER:  Medicare Program
             Diabetes mellitus
             HCFA Ambulatory Care Diabetes Project
             NCQA Health Plan Employer Data and Information Set
             NIH National Diabetes Education Program
             
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Cover
================================================================ COVER


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

March 1997

MEDICARE - MOST BENEFICIARIES WITH
DIABETES DO NOT RECEIVE
RECOMMENDED MONITORING SERVICES

GAO/HEHS-97-48

Medicare Diabetes Care

(108255)


Abbreviations
=============================================================== ABBREV

  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

Letter
=============================================================== LETTER


B-270222

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 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. 


--------------------
\1 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. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

Although 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
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 effectiveness. 

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. 


--------------------
\2 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. 


   BACKGROUND
------------------------------------------------------------ Letter :2

Diabetes affects a significant portion of Medicare beneficiaries and
results 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 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


--------------------
\3 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. 

\4 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. 

\5 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. 

\6 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. 

\7 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). 

\8 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. 

\9 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. 


   MEDICARE BENEFICIARIES WITH
   DIABETES ARE NOT RECEIVING
   RECOMMENDED LEVELS OF
   MONITORING SERVICES
------------------------------------------------------------ Letter :3

Under both fee-for-service and HMO delivery, Medicare beneficiaries
with diabetes are falling far short of receiving recommended levels
of monitoring services, according to available evidence.  A number of
factors, both patient- and physician-related, may contribute to the
low use of these services. 


      PROVIDERS AGREE ON SERVICES
      BUT RECOGNIZE NEED FOR
      FLEXIBILITY ON FREQUENCIES
---------------------------------------------------------- Letter :3.1

The ADA clinical care guidelines reflect the published evidence and
expert opinion on what constitutes quality diabetes care.  The
guidelines recommend monitoring services that with appropriate
follow-up and treatment, may lead to improved health outcomes. 
Receiving these 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. 



                          Table 1
          
          Diabetes Monitoring Services Included in
                        Our Analysis

                  Frequency
Service           per 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 services

Eye exam          One           Identify early signs of
(dilated)                       diabetic retinopathy and
                                refer for treatment

Glycohemoglobin   Two           Assess and monitor
test                            achievement of glycemic
                                control goals

Urinalysis test   One           Monitor kidney function by
                                testing for albumin or
                                protein

Serum             One           Monitor cholesterol as a
cholesterol test                contributor to heart
                                disease and circulatory
                                problems

Flu shot (in      One           General preventive service
season)                         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. 


--------------------
\10 Because these are service targets, 100-percent compliance for all
people with diabetes should not be expected. 


      UNDER FEE-FOR-SERVICE CARE,
      UTILIZATION RATES FOR
      RECOMMENDED SERVICES LEAVE
      ROOM FOR IMPROVEMENT
---------------------------------------------------------- Letter :3.2

Overall, our cohort of about 168,000 Medicare beneficiaries with
diabetes fell far short of receiving the recommended frequencies of
the six monitoring services in 1994.\11 As figure 1 shows, Medicare
beneficiaries with diabetes had the opportunity to receive such
services because 94 percent of them had at least two physician visits
in 1994.  In fact, the 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

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

   (See figure in printed
   edition.)

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, 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, 1994

   (See figure in printed
   edition.)

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 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 races. 

  -- 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.)


--------------------
\11 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. 

\12 We did not determine the primary purpose of the visits, and many
may have been for purposes other than monitoring the patient's
diabetes. 

\13 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. 

\14 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. 

\15 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. 


      LIMITED DATA SUGGEST
      MONITORING IN MEDICARE HMOS
      ALSO FALLS SHORT OF
      RECOMMENDATIONS
---------------------------------------------------------- Letter :3.3

Because HCFA does not require its HMO contractors to report patient-
specific utilization data, we could not systematically assess the use
of recommended monitoring services by beneficiaries with diabetes in
Medicare HMOs.  Unlike fee-for-service providers, Medicare HMOs are
paid a 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 test. 

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
      FACTORS CONTRIBUTE TO
      LESS-THAN-RECOMMENDED
      UTILIZATION
---------------------------------------------------------- Letter :3.4

Although it is unclear what specifically accounts for the less-than-
recommended use of monitoring services, diabetes experts have
identified several factors, including patient and physician attitudes
and practices, that contribute to suboptimal diabetes management in
general.  Many of 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 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. 


   HMO EFFORTS TO MANAGE DIABETES
   CARE ARE VARIED BUT LIMITED
------------------------------------------------------------ Letter :4

Collectively, the 88 HMOs in our survey reported a wide range of
diabetes management efforts; in general, however, most plans' efforts
are limited.  The HMOs identified more than 30 different kinds of
diabetes management 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
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. 


--------------------
\16 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. 


      MOST EFFORTS TO DATE FOCUS
      ON EDUCATION
---------------------------------------------------------- Letter :4.1

Every HMO in our survey reported using at least one type of effort to
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 diabetes. 

  -- 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 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. 


--------------------
\17 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. 

\18 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. 


      MANY PLANS ARE AUGMENTING
      EDUCATION WITH OTHER
      APPROACHES
---------------------------------------------------------- Letter :4.2

Although education may effect short-term behavioral changes, some
experts express concern about the difficulty people with diabetes and
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: 

  -- 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 provided. 

  -- 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,
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 teams. 


--------------------
\19 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. 


      LITTLE EVIDENCE AVAILABLE ON
      EFFECTIVENESS OF DIABETES
      MANAGEMENT EFFORTS
---------------------------------------------------------- Letter :4.3

HMOs in our survey generally had little information about the extent
to which their diabetes management approaches have affected the use
of recommended monitoring services.  Even the plans reporting the
most comprehensive approaches told us that they collect utilization
data on five 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 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 following: 

  -- 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 TARGETED DIABETES FOR
   SPECIAL INITIATIVES, BUT
   EFFECTIVENESS IS STILL LARGELY
   UNKNOWN
------------------------------------------------------------ Letter :5

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.  As in the
private sector, however, most of HCFA's diabetes management
initiatives are either new or not yet under way; therefore, clear
evidence on which approaches are most effective is not yet available. 
In addition, some experts suggest that the agency should do more to
encourage improved diabetes management. 


      DIABETES EDUCATION AND
      SERVICE DELIVERY INITIATIVES
      HAVE BEGUN
---------------------------------------------------------- Letter :5.1

Four years ago, HCFA officials crafted a strategic plan for the
agency that was designed to move it from its traditional role as a
payer to that of a 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 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. 


--------------------
\20 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. 


      HCFA IS PREPARING TO
      IMPLEMENT OTHER INITIATIVES
---------------------------------------------------------- Letter :5.2

HCFA also has committed to encouraging the development of better
data- collection systems for tracking service use.  The agency is
planning several 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. 

  -- 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. 


--------------------
\21 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. 

\22 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. 


   CONCLUSIONS
------------------------------------------------------------ Letter :6

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.  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, 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. 


   AGENCY COMMENTS AND OUR
   RESPONSE
------------------------------------------------------------ Letter :7

HCFA officials generally agreed with the information and issues
discussed in a draft of this report, noting that, "interventions to
prevent the 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. 


---------------------------------------------------------- Letter :7.1

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


METHODOLOGY FOR DETERMINING USE OF
RECOMMENDED DIABETES SERVICES IN
FEE-FOR-SERVICE MEDICARE
=========================================================== Appendix I

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. 


   SELECTING A DIABETES COHORT
   FROM MEDICARE FEE-FOR-SERVICE
   DATA FILES
--------------------------------------------------------- Appendix I:1

We used HCFA's 5% Sample Beneficiary Standard Analytical File (SAF)
to obtain a nationwide representative sample of Medicare
beneficiaries.  This file contains final action claims data for a
5-percent sample of Medicare beneficiaries.  We determined that this
file would provide a sufficient number of claims from which to select
a representative sample of Medicare fee-for-service beneficiaries
with diabetes.  We limited this part 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 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. 


--------------------
\23 We identified our diabetes cohort from 1992 and 1993 claims data,
then reviewed cohort member claims in 1994 for service utilization
rates. 

\24 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. 


   ADDING ENROLLMENT AND
   ELIGIBILITY DATA TO DIABETES
   COHORT RECORDS
--------------------------------------------------------- Appendix I:2

After adding enrollment and eligibility data to our diabetes cohort
records, we could delete certain beneficiary groups from our sample. 
First, we excluded all beneficiaries with a date of death on or
before December 31, 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 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. 


   IDENTIFYING AND COUNTING
   RECOMMENDED DIABETES SERVICES
--------------------------------------------------------- Appendix I:3

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

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 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

Age
----------------------------------------------------------
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

Race
----------------------------------------------------------
White                                  134,512        80.0
Black                                   21,272        12.6
Other                                    6,742         4.0
Unknown                                  5,729         3.4

Sex
----------------------------------------------------------
Male                                    68,799        40.9
Female                                  99,456        59.1

Medicare eligibility category
----------------------------------------------------------
Aged                                   152,200        90.5
Disabled                                16,055         9.5
----------------------------------------------------------


                         Table I.2
          
               Overall Utilization Rates for
                    Recommended Services

Service and frequency                   Number     Percent
----------------------------------  ----------  ----------
Physician visits, two or more per      157,338        93.5
 year
Eye exam, one or more per year          70,475        41.9

Glycohemoglobin
----------------------------------------------------------
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     117,326        69.7
 year
Flu shot, one per fall season\a         74,214        44.1
----------------------------------------------------------
\a 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 Group

Service and              All                        75 and
frequency               ages  Under 65  65 to 74     older
--------------------  ------  --------  --------  --------
Physician visits,       93.5      90.1      93.3      94.6
 two or more per
 year
Eye exam, one or        41.9      27.9      42.5      44.2
 more per year

Glycohemoglobin
----------------------------------------------------------
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     53.1      49.5      52.5      54.6
 year
Serum cholesterol,      69.7      64.6      70.7      69.7
 one per year
Flu shot, one per       44.1      30.4      46.3      44.4
 fall season\a
----------------------------------------------------------
\a The flu shot may be underreported in Medicare claims because
people may obtain it in nonmedical settings



                         Table I.4
          
             Utilization Rates for Recommended
                     Services, by Race

Service and                                         Unknow
frequency            Total   White   Black   Other       n
------------------  ------  ------  ------  ------  ------
Physician visits,     93.5    93.9    91.9    91.8    92.8
 two or more per
 year
Eye exam, one or      41.9    43.1    36.1    37.2    41.4
 more per year

Glycohemoglobin
----------------------------------------------------------
Two or more per       20.9    21.7    15.5    20.1    21.7
 year
One or more per       38.0    39.2    30.7    37.0    38.5
 year
Urinalysis, one       53.1    53.3    52.0    53.5    52.7
 per year
Serum cholesterol,    69.7    70.7    64.2    69.3    68.9
 one per year
Flu shot, one per     44.1    47.1    28.0    35.8    43.6
 fall season\a
----------------------------------------------------------
\a 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

Glycohemoglobin
----------------------------------------------------------------------
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\a               44.1      46.6      42.4
----------------------------------------------------------------------
\a The flu shot may be underreported in Medicare claims because
people may obtain it in nonmedical settings. 



                         Table I.6
          
          Combined Utilization Rates for Four Key
          Services, by Diabetes Cohort Demographic
                      Characteristics

                                   Percent         Percent
Characteristic              receiving none   receiving all
--------------------------  --------------  --------------
Total diabetes cohort                 11.9            10.8

Age
----------------------------------------------------------
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

Race
----------------------------------------------------------
White                                 11.2            11.3
Black                                 15.5             7.7
Other                                 14.7            10.0
Unknown                               12.3            10.4

Sex
----------------------------------------------------------
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. 



                                        Table I.7
                         
                            Utilization Rates for Recommended
                                    Services, by State

                                    Percent receiving recommended services
                     --------------------------------------------------------------------
             Number
                 of    Four
             cohort     key  Physic
            diabeti  servic     ian       Eye  Glycohemoglo  Urinalys  Cholestero     Flu
State            cs      es  visits      exam     bin (two)        is           l    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
Connecticu    2,480    14.6    95.0      47.2          25.2      60.1        67.8    47.1
 t
Delaware        548    10.8    94.2      45.8          18.4      44.0        68.8    44.5
District        474    13.3    93.9      43.0          19.8      51.9        76.6    28.7
 of
 Columbia
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
Massachuse    4,283    14.8    95.0      53.1          27.6      54.3        68.0    27.3
 tts
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
Mississipp    2,398     4.7    90.4      36.0           9.3      57.0        61.8    39.9
 i
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             730     9.9    93.7      45.9          26.9      46.7        65.8    43.6
 Hampshire
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         5,412     8.5    92.9      41.0          15.3      54.6        66.4    42.4
 Carolina
North           400    11.5    89.8      46.0          23.8      57.3        67.8    51.8
 Dakota
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
Pennsylvan   11,794     7.9    95.6      37.7          22.1      46.1        69.4    49.1
 ia
Rhode           801    12.6    95.1      47.9          23.2      58.4        58.1    43.1
 Island
South         2,947     6.5    92.9      37.5          10.4      53.7        60.4    42.6
 Carolina
South           444    10.8    88.1      40.1          21.4      55.9        64.0    50.0
 Dakota
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          1,756     6.4    92.9      35.7          14.1      47.6        64.8    40.7
 Virginia
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      168,255    10.8    93.5      41.9          20.9      53.1        69.7    44.1
 States
-----------------------------------------------------------------------------------------
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. 


--------------------
\25 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 Terminology. 


METHODOLOGY FOR DETERMINING USE OF
DIABETES MANAGEMENT APPROACHES BY
MEDICARE HMOS
========================================================== Appendix II

This appendix discusses our examination of diabetes management
efforts by Medicare HMOs.  It briefly describes our methodology and
the key findings from our survey. 


   METHODOLOGY
-------------------------------------------------------- Appendix II:1

To better understand the approaches to diabetes management used by
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). 



                               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

Location
----------------------------------------------------------------------
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. 


--------------------
\26 HCFA, Monthly Report of Medicare Managed Care Plans (Washington,
D.C.:  Apr.  1996), http://www.hcfa.gov/stats/monthly.htm (cited Apr. 
12, 1996). 


   SURVEY RESULTS
-------------------------------------------------------- Appendix II:2

The 88 HMOs reported a wide range of diabetes management efforts,
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
                                                                  HMOs
                                                                respon
                                                                  ding
Survey question                                                  "yes"
--------------------------------------------------------------  ------
Does your plan occasionally include information about diabetes      82
 in regular newsletters mailed to all enrollees?
Does your plan provide (diabetes-related) information to            71
 physicians through newsletters or mailings to physicians?
Does your plan have health professionals, such as diabetes          68
 educators, nutritionists, or diabetes nurses, available for
 enrollee education?
Does your plan have any policies or procedures that are used        62
 to guide physicians' treatment of diabetic enrollees, such as
 guidelines, practice parameters, or information briefs?
Does your plan maintain a list or registry of your enrollees      61\a
 with type II diabetes?
Does your plan use case managers to monitor the medical care        60
 that your diabetic enrollees receive?
Has your plan set performance goals for diabetes care?              58
Does your plan mail educational newsletters or pamphlets about      41
 diabetes care to your diabetics?
Does your plan operate any type of program designed to              31
 consolidate services for diabetics?
Does your plan have a computer system that generates reminders      24
 for physicians when specific patients are due for specific
 services?
Can you estimate about what proportion of all your Medicare         20
 enrollees have type II diabetes?
----------------------------------------------------------------------
\a 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 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)

                                 Mailings
                                       to      Allied
                     Clinical   enrollees      health                Mailings
Descriptive          practice        with  profession        Case          to    Diabetes
variable           guidelines    diabetes       als\a  management  physicians    registry
-----------------  ----------  ----------  ----------  ----------  ----------  ----------
Model type
-----------------------------------------------------------------------------------------
Staff                      92          46          85          77          69          69
Group                      80          33          87          53          80          73
Independent                63          50          73          70          83          68
 practice
 association

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               93          20          87          60          80          60
 years

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

Location
-----------------------------------------------------------------------------------------
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
-----------------------------------------------------------------------------------------
\a Such as certified diabetes educators or nutritionists. 



                                        Table II.4
                         
                           HMOs Efforts to Monitor Recommended
                             Services by Plan Characteristic
                                        (Percent)

Descriptive                    Glycohemoglobi              Choleste
variable             Eye exam               n  Urinalysis       rol  Flu shot  Foot exams
-----------------  ----------  --------------  ----------  --------  --------  ----------
Model type
-----------------------------------------------------------------------------------------
Staff                      55              46          55        46        46          36
Group                      92              69          54        46        62          31
Independent                95              60          55        50        45          36
 practice
 association

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               67              42          33        33        50          25
 years

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

Location
-----------------------------------------------------------------------------------------
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
-----------------------------------------------------------------------------------------



(See figure in printed edition.)Appendix III
COMMENTS FROM THE HEALTH CARE
FINANCING ADMINISTRATION
========================================================== Appendix II



(See figure in printed edition.)


MAJOR CONTRIBUTORS TO THIS REPORT
========================================================== Appendix IV

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


*** End of document. ***