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. Medicare Beneficiaries With Diabetes Are Not Receiving Recommended Levels of Monitoring Services

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. 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. 2.) The use of diabetes monitoring services varied by geographic area. Many of these factors are not unique to diabetes management; they also affect delivery of preventive care for many other chronic conditions. 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. 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. 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. 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;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. Most Medicare beneficiaries with diabetes have had the disease for many years and are likely to have other serious chronic conditions. Methodology for Determining Use of Recommended Diabetes Services in Fee-for-Service Medicare

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. These numbers provided numerator data to calculate the percentage of cohort members with diabetes who received the services at recommended intervals. 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.
Why GAO Did This Study

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.

What GAO Found

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 initiatives prove cost-effective, they may help promote better management of diabetes care.