Medicare: Provision of Key Preventive Diabetes Services Falls Short of
Recommended Levels (Testimony, 04/11/97, GAO/T-HEHS-97-113).

GAO discussed its recent report on preventive and monitoring services
provided 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 Medicare health
maintenance organizations (HMO) are doing to improve delivery of
recommended diabetes services; and (3) the activities that the Health
Care Financing Administration (HCFA) supports to address these service
needs for Medicare beneficiaries with diabetes.

GAO noted that: (1) while experts agree that regular use of preventive
and monitoring services can help minimize the complications of diabetes,
most Medicare beneficiaries with diabetes do not receive these services
at recommended intervals; (2) this is true both in traditional
fee-for-service Medicare, which serves about 90 percent of all
beneficiaries, and in managed care delivery; (3) the efforts of Medicare
HMOs to improve diabetes care have been varied but generally limited,
with most plans reporting that they have focused on educating their
enrollees with diabetes about self-management and their physicians about
the need for preventive and monitoring services; (4) very few plans have
developed comprehensive diabetes management programs; and (5) at the
federal level, HCFA has targeted diabetes for special emphasis and has
begun to test preventive care initiatives, but like the HMOs, HCFA's
efforts are quite recent and the agency does not yet have results that
would allow it to evaluate effectiveness.

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

 REPORTNUM:  T-HEHS-97-113
     TITLE:  Medicare: Provision of Key Preventive Diabetes Services 
             Falls Short of Recommended Levels
      DATE:  04/11/97
   SUBJECT:  Health care programs
             Health maintenance organizations
             Managed health care
             Health care services
             Diseases
             Health resources utilization
             Health services administration
             Monitoring
             Education or training
             Medical examinations
IDENTIFIER:  Medicare Program
             Diabetes mellitus
             NCQA Health Plan Employer Data and Information Set
             NIH National Diabetes Education Program
             HCFA Ambulatory Care Diabetes Project
             
******************************************************************
** This file contains an ASCII representation of the text of a  **
** GAO report.  Delineations within the text indicating chapter **
** titles, headings, and bullets are preserved.  Major          **
** divisions and subdivisions of the text, such as Chapters,    **
** Sections, and Appendixes, are identified by double and       **
** single lines.  The numbers on the right end of these lines   **
** indicate the position of each of the subsections in the      **
** document outline.  These numbers do NOT correspond with the  **
** page numbers of the printed product.                         **
**                                                              **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced.  Tables are included, but    **
** may not resemble those in the printed version.               **
**                                                              **
** Please see the PDF (Portable Document Format) file, when     **
** available, for a complete electronic file of the printed     **
** document's contents.                                         **
**                                                              **
** A printed copy of this report may be obtained from the GAO   **
** Document Distribution Center.  For further details, please   **
** send an e-mail message to:                                   **
**                                                              **
**                                            **
**                                                              **
** with the message 'info' in the body.                         **
******************************************************************


Cover
================================================================ COVER


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

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

MEDICARE - PROVISION OF KEY
PREVENTIVE DIABETES SERVICES FALLS
SHORT OF RECOMMENDED LEVELS

Statement of Bernice Steinhardt, Director
Health Services Quality and Public Health Issues
Health, Education, and Human Services Division

GAO/T-HEHS-97-113

GAO/HEHS-97-113T


(108325)


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

  ADA - American Diabetes Association
  CDC - Center for Disease Control
  HCFA - Health Care Financing Administration
  HEDIS - Health Plan Employer Data and Information Set
  HMO - health mainenance organization
  PRO - peer review organization

MEDICARE:  PROVISION OF KEY
PREVENTIVE DIABETES SERVICES FALLS
SHORT OF RECOMMENDED LEVELS
============================================================ Chapter 0

Mr.  Chairman and Members of the Subcommittee: 

We are pleased to be here today to discuss our recent report on
preventive and monitoring services provided to Medicare beneficiaries
with diabetes.\1 Diabetes is a prevalent, costly, chronic disease
that has substantial effects on the Medicare program:  at least 1 in
10 beneficiaries is diagnosed with diabetes, and on average these
beneficiaries cost Medicare considerably more than those without
diabetes.  Most experts agree that preventive care--including both
appropriate medical management and patient self-management--can
improve the quality of life for people with diabetes, and it may help
control costs.  Prevention for diabetes aims to slow the disease's
progression through screening, monitoring, and treating conditions to
keep them from worsening and becoming more costly. 

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

At your request, we examined how well the health care system provides
preventive services to Medicare beneficiaries with diabetes.  We
focused our review on the following questions:  (1) To what extent
are Medicare beneficiaries with diabetes receiving recommended levels
of preventive and monitoring services?  (2) What are Medicare health
maintenance organizations (HMO) doing to improve delivery of
recommended diabetes services?  (3) What activities does the Health
Care Financing Administration (HCFA) support to address these service
needs for Medicare beneficiaries with diabetes?  To respond to these
questions, we identified a representative sample of more than 168,000
people with diabetes in the Medicare fee-for-service program and
reviewed their service claims records for 1994.  We also surveyed 88
HMO plans serving Medicare beneficiaries on their approaches to
preventive diabetes care and conducted follow-up interviews with 12
of those plans. 

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


--------------------
\1 Medicare:  Most Beneficiaries With Diabetes Do Not Receive
Recommended Monitoring Services (GAO/HEHS-97-48, Mar.  28, 1997). 


   MEDICARE BENEFICIARIES WITH
   DIABETES ARE NOT RECEIVING
   RECOMMENDED LEVELS OF
   MONITORING SERVICES
---------------------------------------------------------- Chapter 0:1

The American Diabetes Association's (ADA) clinical care
recommendations, which reflect the published research evidence and
expert opinion, are widely accepted as guidance on what constitutes
quality diabetes care.  We selected for review six of ADA's
recommended monitoring services that can be measured using Medicare
claims data (see table 1).  The service frequencies recommended in
table 1 generally apply to the average person with
noninsulin-dependent diabetes, the type that accounts for more than
90 percent of diabetics in Medicare.  Of course, some individuals may
need more or fewer services depending on their age, medical
condition, whether they use insulin, or how well their blood sugar is
controlled. 



                          Table 1
          
          Diabetes Monitoring Services Included in
                        Our Analysis

                   Frequency
Service             per year  Purpose
----------------  ----------  ----------------------------
Physician visits        2 -4  Monitor general health and
                               diabetes control; order and
                               review lab tests; conduct
                               foot exams; and refer to
                               other services
Eye exam                   1  Identify early signs of
 (dilated)                     diabetic retinopathy and
                               refer for treatment
Glycohemoglobin            2  Assess and monitor
 test                          achievement of glycemic
                               control goals
Urinalysis test            1  Monitor kidney function by
                               testing for albumin or
                               protein
Serum                      1  Monitor cholesterol as
 cholesterol                   contributor to heart
 test                          disease and circulatory
                               problems
Flu shot (in               1  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). 

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

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

   (See figure in printed
   edition.)

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

   Figure 2:  Percentage 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. 

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

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


      PATIENT AND PHYSICIAN
      FACTORS CONTRIBUTE TO
      LESS-THAN-RECOMMENDED
      UTILIZATION
-------------------------------------------------------- Chapter 0:1.1

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

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

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

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


   HMO EFFORTS TO MANAGE DIABETES
   CARE ARE VARIED BUT LIMITED
---------------------------------------------------------- Chapter 0:2

We surveyed 88 Medicare HMO contractors about their efforts to manage
diabetes care, with particular attention to how they encouraged the
use of preventive and monitoring services.  We expected that the HMOs
might have identified diabetes as a problem area and might have taken
steps to implement management approaches.  These HMOs did in fact
report a wide range of diabetes management efforts, and a few were
developing comprehensive programs; but most plans' efforts were
limited primarily to educational approaches.  Most efforts were
initiated recently, and little is known yet about their
effectiveness. 

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

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


      MANY PLANS ARE AUGMENTING
      EDUCATION WITH OTHER
      APPROACHES
-------------------------------------------------------- Chapter 0:2.1

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

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


      LITTLE EVIDENCE AVAILABLE ON
      EFFECTIVENESS OF DIABETES
      MANAGEMENT EFFORTS
-------------------------------------------------------- Chapter 0:2.2

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

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


   HCFA HAS TARGETED DIABETES FOR
   SPECIAL INITIATIVES, BUT
   EFFECTIVENESS IS STILL LARGELY
   UNKNOWN
---------------------------------------------------------- Chapter 0:3

HCFA has identified diabetes as a major health problem in the
Medicare population and has targeted the disease for special
initiatives to improve physician and patient awareness, service
delivery, and, ultimately, patient health outcomes.  Among these
initiatives is the National Diabetes Education Program, in which HCFA
is participating with CDC and the National Institute of Diabetes and
Digestive and Kidney Diseases.  This program is being designed to
increase general public awareness of diabetes as well as patient and
provider education about diabetes and practice guidelines. 

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

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

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


   CONCLUSIONS
---------------------------------------------------------- Chapter 0:4

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

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


-------------------------------------------------------- Chapter 0:4.1

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


   CONTRIBUTORS
---------------------------------------------------------- Chapter 0:5

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


*** End of document. ***