Arizona Health Care Cost Containment System
Arizona Long Term Care System (ALTCS) Performance Measure

PERFORMANCE MEASURES FOR DIABETES CARE
Measurement Period: October 1, 2004, through September 30, 2005
Prepared by the Division of Health Care Management
November 2006
Anthony D. Rodgers
Director, AHCCCS

For questions or comments about this report, contact:
Rochelle Tigner
Quality Improvement Manager, Clinical Quality Management
Division of Health Care Management, AHCCCS
(602) 417-4683
rttigner@ahcccs.state.az.

Arizona Health Care Cost Containment System (AHCCCS)
Arizona Long Term Care System (ALTCS)
PERFORMANCE MEASURES FOR DIABETES CARE
For the Measurement Period October 1, 2004, through September 30, 2005
INTRODUCTION

1

SIGNIFICANCE OF THE MEASURES

2

STUDY METHODS
Population ..................................................................................................................
Sample Frame ............................................................................................................
Measurement Period ..................................................................................................
Data Sources ..............................................................................................................
Data Collection ..........................................................................................................
Data Quality and Reliability ......................................................................................
Study Indicators .........................................................................................................
Performance Measure Goals ......................................................................................
National Benchmarks .................................................................................................

3
3
3
3
3
4
4
4
4

RESULTS AND ANALYSIS
Included Cases ...........................................................................................................
Hb A1c Testing ..........................................................................................................
Lipid Screening ..........................................................................................................
Eye Examinations ......................................................................................................

5
5
5
5

DISCUSSION
Overall Results ...........................................................................................................
Contractor Performance .............................................................................................
Quality Improvement Efforts .....................................................................................
Conclusion .................................................................................................................

6
6
6
7

REFERENCES

7

TABLES AND FIGURES

9

APPENDIX: METHODOLOGY AND TECHNICAL SPECIFICATIONS

i

Arizona Health Care Cost Containment System (AHCCCS)
Arizona Long Term Care System (ALTCS)
PERFORMANCE MEASURES FOR DIABETES CARE
For the Measurement Period October 1, 2004, through September 30, 2005

INTRODUCTION
boomers” who are aging and living longer
than previous generations. A sedentary
lifestyle and a dramatic rise of obesity in
the U.S. population also are increasing the
incidence of diabetes.7

The federal Centers for Disease Control
and Prevention (CDC) estimates that more
than 20 million Americans age 20 years
and older, or 9.6 percent of all people in
this age group, have diabetes. About 1.5
million new cases of diabetes were
diagnosed among people 20 years and
older in 2005.1

Nearly 20 percent of all
people 60 and older have
diabetes.

An estimated 244,000 Arizona adults had a
diagnosis of diabetes in 2002, the most
recent year for which state-specific data
are available.2

Centers for Disease Control and Prevention

Diabetes was the sixth leading cause of
death in the United States in 2002, causing
or contributing to at least 224,000 deaths. 3

About one out of every 10 health care
dollars in the United States is spent on
diabetes and its complications. Total U.S.
expenditures related to diabetes were
approximately $132 billion in 2002 – $92
billion in direct medical costs and another
$40 billion in indirect costs because of
missed work days or other losses in
productivity.8 At least 4 million
hospitalizations and more than 26 million
outpatient visits annually in the U.S. are
associated with diabetes.9,10

In the United States, Hispanics, blacks,
American Indians and Alaska natives are
two to three times more likely to have
diabetes than non-Hispanic whites. The
prevalence of diabetes also is higher
among older Americans – nearly 20
percent of all people 60 and older have
diabetes – as well as among people with
low socioeconomic status and those
covered by Medicaid. 1,4

Diabetes is the leading cause of end-stage
kidney disease and new cases of blindness
among adults. It also is responsible for
more than 60 percent of nontraumatic
lower-limb
amputations.
Other
complications include heart disease, stroke,
and nervous system disorders.3

The number of people in the United States
with diagnosed diabetes has more than
doubled in the last 15 years.5 The
prevalence of diabetes in Arizona also has
increased during that time.6 Contributing to
this increase is the large number of “baby

1

The purpose of this study is to monitor
performance of health plans contracted
with the Arizona Long Term Care System
(ALTCS) for diabetes-related measures.
These measures evaluate the percent of
ALTCS members with diabetes who
receive certain clinical services to detect
and prevent or reduce complications. This
report summarizes current results of these
Performance Measures.

Diabetes-related costs were
estimated to be $132 billion
in the U.S. in 2002.
Study conducted by the Lewin Group. Inc.
for the American Diabetes Association

SIGNIFICANCE OF THE MEASURES
education of patients in self-management
techniques.5,11

With diabetes, sustained high blood sugars
result in microvascular complications; that
is, damage to the very fine blood vessels of
the eyes, peripheral nerves and kidneys.
Diabetic retinopathy (damage to the retina
of the eye) causes 12,000 to 24,000 new
cases of blindness each year. Up to 70
percent of people with diabetes have mild
to severe forms of nervous system damage,
including impaired sensation or pain in the
feet or hands, slowed digestion of food,
carpal tunnel syndrome and other nerve
problems.3 Diabetes is the leading cause of
end stage renal (kidney) disease.

Glucose
Control
––
Control
of
hyperglycemia (increased blood sugar) is
critical to reducing both the incidence and
progression of complications associated
with diabetes. Physicians utilize a
glycosylated hemoglobin, or Hb A1c, test
to monitor patients’ blood glucose levels.
This test indicates a person’s average
glucose level over a two- to three-month
period by measuring the amount of glucose
that has bonded with hemoglobin in the
body’s red blood cells.

Macrovascular complications of diabetes
include coronary and peripheral artery
disease, which may lead to heart attack or
stroke, as well as amputations.

Studies in the United States and abroad
have shown that improved glycemic
control greatly benefits people with
diabetes. In general, for every percentage
point decrease in Hb A1c levels, the risk of
developing microvascular complications is
reduced by 35 to 40 percent. 3,12,13

As with many diseases, other conditions
(known as comorbid conditions) may be
present. For example, the increased
prevalence of lipid abnormalities found
with type 2 diabetes contributes to higher
rates of cardiovascular disease among
diabetics.11

Lipid Management –– Managing lipid
levels has been shown to reduce
macrovascular complications affecting the
heart, brain and legs, especially in people
who have a history of cardiovascular
problems.11,12 Control of cholesterol and
lipids
can
reduce
cardiovascular
complications by 20 to 50 percent.3

Despite its deadly effects, diabetes can be
controlled. Many complications of the
disease can be prevented or reduced with
early detection, improved care and better

2

exams and timely treatment, including
laser
therapy,
could
reduce
the
development of severe vision loss by up to
60 percent.3 People with diabetes should
have
comprehensive
dilated
eye
examinations by ophthalmologists or
optometrists, in order to detect and treat
retinopathy and prevent vision loss.

A fasting lipid profile is performed to
measure total cholesterol (TC), highdensity
lipoproteins
(HDL)
and
triglycerides. These results are used to
calculate
and
manage
low-density
lipoprotein (LDL) levels.
Eye Care — It is estimated that regular eye

STUDY METHODS
had a diagnosis of type 1 or type 2
diabetes in the measurement period or the
year prior to the measurement period.
•

AHCCCS used Health Plan Employer Data
and Information Set (HEDIS) 2005
specifications
from
the
National
Committee for Quality Assurance (NCQA)
as a guideline for measurement of diabetes
care services. HEDIS methodology
includes six indicators of comprehensive
diabetes care. AHCCCS has identified
three of these indicators for performance
measurement: Hb A1c testing, lipid
screening, and retinal (eye) exams.

Members were identified as having type 1
or type 2 diabetes by either pharmacy or
encounter data (records of claims paid by
Contractors for covered services). For
example, a member was identified as
having diabetes if he or she had one faceto-face encounter with a diagnosis of
diabetes in an acute inpatient or emergency
room setting during the measurement
period or the previous year.

Population
The population included in this
measurement consisted of elderly or
physically disabled (E/PD) members
enrolled with ALTCS-contracted health
plans (Contractors).

Data Sources
AHCCCS uses an automated data system
known
as
the
Prepaid
Medical
Management
Information
System
(PMMIS). AHCCCS enrollment and
encounter data contained in PMMIS were
used to select sample members for this
study and collect some data. Medical and
case management records collected by
Contractors were used to supplement
encounter data.

Measurement Period
The measurement period for this study was
the AHCCCS contract year from October
1, 2004, through September 30, 2005.
Sample Frame
The sample frame consisted of E/PD
members who:
• were ages 18 through 75 years as of
September 30, 2005,
• were continuously enrolled with one
ALTCS
Contractor
during
the
measurement period with no more than one
gap in enrollment, not exceeding 31 days,
• were enrolled with the Contractor on
September 30, 2005, and

Data Collection
As many as 80 percent of ALTCS elderly
and physically disabled members also are
covered by Medicare. Medicare is the
primary payer for these “dually enrolled”
members, and AHCCCS does not receive
encounters for services paid for by another
program or insurer.
3

one or more lipid screenings during the
measurement period or the preceding year.

AHCCCS initially collected data on
diabetes services from its encounter
subsystem. When encounters for specific
services within the measurement period
(or, in some cases the previous year) were
not found in encounter data, AHCCCS
provided demographic data for those
sample members to the appropriate
Contractors using a standardized electronic
data collection tool.

Retinal examinations — This indicator
measured the percent of members who had
a retinal exam by an optometrist or
ophthalmologist during the measurement
period or the preceding year
Performance Measure Goals
AHCCCS has established Contractor
performance standards for these measures.
If ALTCS Contractors have achieved the
AHCCCS minimum performance standard
(MPS) for any measure, they should strive
to meet the AHCCCS goal.

Contractors collected data for additional
services provided to their members,
including some services that were paid for
by Medicare, from their claims systems,
case management records and medical
records. This information was entered into
the electronic tool by Contractor staff,
according to detailed instructions from
AHCCCS.
Data Quality and Reliability
AHCCCS conducts validation studies to
evaluate the completeness of encounter
data, compared with the corresponding
medical records. Based on the most recent
study of encounters submitted by longterm care Contractors, the encounter
omission rate was less than 5 percent.

Measure

MPS

Goal

Hb A1c testing

75 %

77%

Lipid screening

76%

78%

Retinal exams

45%

47%

These performance standards are designed
to provide milestones for Contractors to
meet in achieving the AHCCCS longrange goals for these measures, known as
benchmarks. The AHCCCS-established
benchmarks are: Hb A1c testing, 88
percent; lipid screening, 85 percent; and
retinal exams, 64 percent.

In order to document the reliability of data
collected outside of the AHCCCS
encounter system for this study,
Contractors were required to submit hard
copies of the appropriate sections of
medical or case management records, or
documentation of a paid claim, with their
electronic data tools.

National Benchmarks
NCQA reports national averages for
Medicaid health plans for these measures.
The HEDIS 2004 means (averages)
reported for Medicaid plans nationally
were used to establish the current
AHCCCS minimum standards in 2005.
HEDIS rates for the 90th percentile of
plans were used to set the benchmarks.

Study Indicators
Hb A1c testing — This indicator measured
the percent of members who had one or
more Hb A1c tests during the measurement
period.

The 2005 mean for annual Hb A1c testing
among Medicaid plans was 76.2 percent.
The mean for lipid screening was 80.5
percent. The mean for retinal exams was
48.6 percent.

Lipid (LDL-C) screening — This indicator
measured the percent of members who had

4

R E S U L T S AND ANALYSIS
and goal for this measure; one exceeded
the AHCCCS benchmark (Figure 2). These
were the same three Contractors that
achieved the highest rates for Hb A1c
testing, and exceeded the AHCCCS goal
for that measure.

Included Cases
This measurement included 1,019 ALTCS
members with diabetes who were enrolled
with six long-term care Contractors during
the measurement period.
Hb A1c Testing
The overall rate of members who received
an Hb A1c test during the measurement
period was 74.8 percent, compared with
75.2 percent in the previous period (Table
1). The difference in rates is not
statistically significant (p=.845).

Retinal Examinations
The overall rate of members who had a
dilated eye (retinal) examination in the
measurement period or the preceding year
was 66.6 percent, compared with 51.1
percent in the previous measurement
(Table 3). The increase is statistically
significant (p<.001).

Rates by Contractor ranged from 67.7
percent to 90.2 percent. However, none of
the Contractors demonstrated a statistically
significant change from the previous
measurement period.

Rates by Contractor ranged from 51.7
percent to 85.6 percent. Four Contractors
showed a significant improvement, with
relative increases ranging from 15.4
percent to 98.8 percent. One Contractor
experienced a relative decline of 22.5
percent (p=.026).

Three Contractors exceeded both the
AHCCCS minimum performance standard
and goal for this measure; one exceeded
the AHCCCS benchmark (Figure 1).

All Contractors achieved both the
minimum performance standard and goal
for this measure; three surpassed the
benchmark (Figure 3).

Lipid (LDL-C) Screening
The overall rate of members who had an
LDL-C screening, or fasting lipid profile,
during the measurement period or the
preceding year was 73.6 percent, compared
with 70.8 percent in the previous period
(Table 2). The difference in rates is not
statistically significant (p=.117).

ALTCS Diabetes Care Rates,
CYE 2005 vs. CYE 2004
100
80

Rates by Contractor ranged from 46.2
percent to 90.2 percent. One Contractor
demonstrated a relative increase of 11.8
percent (p=.033), and one Contractor
showed a relative decline of 32.5 percent
(p=.002).

60
40
20
0
Hb A1c

Three Contractors exceeded both the
AHCCCS minimum performance standard

Lipid

CYE 2005

5

Eye

CYE 2004

DISCUSSION
well as information on successful
strategies for increasing the use of
preventive-care services, such as Hb A1c
testing, lipid screening and eye exams.
Successful strategies used in other
programs include:14-19
•
Automated reminders by telephone,
advising patients that they are due for tests.
•
Frequent nurse follow-up by phone,
especially as part of a case management or
disease management program.
•
Group visits with multidisciplinary
provider teams; e.g., including a physician,
pharmacist, diabetes educator, nutritionist,
and/or mental health professional as part of
the care team.
•
Culturally relevant patient materials or
interventions, such as food preparation
classes that incorporate traditional foods,
in diabetes education.
•
Social support groups, which allow
patients to share experiences, and give
health care professionals opportunities to
further encourage the lifestyle changes that
are usually necessary to control diabetes.

Overall Results
The AHCCCS overall rates did not show
improvement in two of the three measures,
and the rates for these two measures fall
short of the comparable HEDIS averages
for Medicaid health plans nationwide.
However, the rate for retinal exams
increased markedly in this measurement,
and is above the 90th percentile for
Medicaid plans nationally.
Long-term trend data for these measures
are not available because AHCCCS has
been measuring these diabetes indicators
for only two years using the current
methodology.
Contractor Performance
Three Contractors ― Cochise Health
Systems, Mercy Care Long Term Care and
Pinal/Gila County Long Term Care ― met
the AHCCCS minimum performance
standards as well as the AHCCCS goals
for all three diabetes measures.
The three remaining ALTCS Contractors
― Evercare Select, Pima Health System
Long Term Care and Yavapai County
Long Term Care ― met the minimum
performance standard for retinal exams
only. These Contractors will be required to
implement Corrective Action Plans to
bring their rates for Hb A1c testing and
lipid screening up to the AHCCCS
Minimum Performance Standards.

AHCCCS Contractors have utilized a
variety of strategies to improve care of
their diabetic members. These include
member education, monitoring and follow
up through disease management programs;
developing and distributing practice
guidelines to primary care physicians
(PCPs), and advising PCPs of diabetic
members who are due for specific services.
Pinal/Gila County Long Term Care ―
which had the highest rates for Hb A1c
testing and lipid screening and the secondhighest rate for eye exams ― has
incorporated into its contracts with home
and community-based service providers
requirements to ensure that members make
regular visits to their physicians to have
these tests performed.

It should be noted that AHCCCS increased
minimum standards significantly for this
measurement period.
Quality Improvement Efforts
In order to assist ALTCS Contractors with
improving their rates for these measures,
AHCCCS has provided health plans with
educational materials and opportunities, as
6

2

The health plan profiles performance of
individual assisted living facilities and
attendant care providers to drive
improvements. In addition, nurses with the
health plan’s disease management program
maintain close communication with
physicians to coordinate services.

Centers for Disease Control and Prevention.
Diabetes surveillance system: State-specific
estimates of diagnosed diabetes among adults.
Centers for Disease Control and Prevention,
National Center for Chronic Disease
Prevention and Health Promotion. Available
at:
http://www.cdc.gov/diabetes/statistics/prev/stat
e/table15.htm. Accessed September 15, 2004.
3
Centers for Disease Control and Prevention.
National diabetes fact sheet 2005. Atlanta, GA.
U.S. Department of Health and Human
Services, Centers for Disease Control and
Prevention.
2005.
Available
at:
http://www.cdc.gov/diabetes/pubs/factsheet.ht
m. Accessed July 27, 2006.
4
National Center for Health Statistics. Health,
United States, 2004. Table 8: Age-adjusted
percentages (with standard errors) of selected
diseases and conditions among persons 18
years of age and over, by selected
characteristics: United states, 2003. Centers for
Disease Control and Prevention. Hyattsville,
Maryland:
2004.
Available
at:
http://www.cdc.gov/nchs/hus.htm. Accessed
September 20, 2005.
5
Centers for Disease Control and Prevention.
Diabetes: disabling, deadly, and on the rise.
Centers for Disease Control and Prevention,
National Center for Chronic Disease
Prevention and Health Promotion. Available
at:
http://www.cdc.gov/nccdphp/aag/pdf/aag_ddt2
004.pdf. Accessed September 22, 2006.
6
Centers for Disease Control and Prevention,
National Center for Chronic Disease
Prevention and Health Promotion. Behavioral
Risk Factor Surveillance System Prevalence
Data..
Available
at:
http://apps.nccd.cdc.gov/brfss/display_c.asp?yr
_c=2004&yr=2005&cat=DB&state=AZ&bkey
=20050405&qkey=1363&qtype=C&grp=0&S
UBMIT2=Compare. Accessed September 15,
2004, and September 22, 2006.
7
National
Diabetes
Information
Clearinghouse. Diabetes overview. National
Institute of Diabetes and Digestive and Kidney
Diseases.
Available
at:
http://diabetes.niddk.nih.gov/dm/pubs/overvie
w/index.htm#who. Accessed August 30, 2005.

Conclusion
Diabetes can be devastating and costly.
However, clinical services that help
monitor and control glucose and lipid
levels, or detect retinal damage early, can
help reduce the burden of disease.
A
related
AHCCCS
Performance
Improvement Project (PIP) focusing on Hb
A1c testing showed that rates of testing
among ALTCS members increased
significantly from CYE 2001 through CYE
2004. These results were achieved through
an intensive focus on quality improvement.
For example, Cochise Health Systems, in its
final report on the PIP, stated that it “has
been literally bombarding members and
providers with information about diabetes.
(Contractor staff feel) that there is a direct
correlation between our educational
interventions and the steady, sustained
improvement in both the Hb A1c testing
indicator and the poor Hb A1c control
indicator.”
Contractors must maintain an active focus
on member and provider outreach related
to diabetes care, in order to continue this
kind of improvement. AHCCCS will
consider increasing minimum performance
standards, particularly for retinal exams, to
promote improvement in these measures.
REFERENCES
1
American Diabetes Association. Total
prevalence of diabetes and pre-diabetes.
Available at:
http://www.diabetes.org/diabetesstatistics/prevalence.jsp. Accessed July 27,
2006.

7

8

Americans. Diabetes Care. 2002; 25(2):259268. Available at:
http://care.diabetesjournals.org/cgi/content/full
/25/2 Accessed September 22, 2006..
17
Gilliland SS, Azen SP, Perez GE, Carter JS.
Strong in body and spirit: Lifestyle
intervention for Native American adults with
diabetes in New Mexico. Diabetes Care. 2002;
25(1):78-83. Available at:
http://care.diabetesjournals.org/cgi/content/abs
tract/full/25/1 Accessed September 22, 2006..
18
Sadur CN, Moline N, Costa M, et al.
Diabetes management in a health maintenance
organization: efficacy of care management
using cluster visits. Diabetes Care. 1999;
22(12):2011-2017.
Available
at:
http://care.diabetesjournals.org/cgi/content/abs
tract/22/12. Accessed September 22, 2006.
19
Glazier R, Bajcar J, Kennie N, Willson K. A
systematic review of interventions to improve
diabetes care in socially disadvantaged
populations.
Diabetes
Care.
1999;
22(12):2011-2017.
Available
at:
http://care.diabetesjournals.org/cgi/content/abs
tract/29/7. Accessed September 22, 2006.

American Diabetes Association. Economic
costs of diabetes in the US in 2002. Diabetes
Care.
2003;26:917-932.
Available
at:
http://www.care.diabetesjournals.org/cgi/conte
nt/full/26/3/917. Accessed March 19, 2003.
9
Centers for Disease Control and Prevention.
Indicators for chronic disease surveillance.
MMWR. 2004; 53(RR-11):100. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtm
l/rr5311a1.htm Accessed September 22, 2006.
10
Beers MH, Berkow R, eds. The Merck
Manual of Diagnosis and Therapy. 17th ed.
Whitehouse Station, NJ: Merck Research
Laboratories; 1999.
11
American Diabetes Association. Standards
of medical care in diabetes − 2006. Diabetes
Care. 2006; 29:S4-S42. Available at:
http://care.diabetesjournals.org/cgi/content/full
/29/suppl_1/s4. Accessed July 27, 2006.
12
Centers for Disease Control and Prevention,
National Center for Chronic Disease
Prevention and Health Promotion. Preventing
diabetes and its complications. Available at:
http://www.cdc.gov/nccdphp/publications/facts
heets/Prevention/diabetes.htm.
Accessed
September 22, 2006.
13
Osterweil N. Tight glucose control may
provide long-term benefits in diabetics.
Medscape Medical News, 2004. Available at:
http://www.medscape.com/viewarticle/480466.
Accessed June 16, 2004.
14
Karter AJ, Ferrara A, Darbibiab JA,
Ackerson LM, Selby JV. Self-monitoring of
blood glucose: language and financial barriers
in a managed care population with diabetes.
Diabetes
Care.
2000;
23(4):477-483.
Available at:
http://care.diabetesjournals.org/cgi/content/abs
tract/23/4..
15
Piette JD, Weinberger M, Kraemer FB,
McPhee SJ. Impact of automated calls with
nurse follow-up on diabetes treatment
outcomes in a department of veterans affairs
health care system. Diabetes Care. 2001;
24(2):202-208.
Available
at:
http://care.diabetesjournals.org/cgi/content/abs
tract/full/24/2. Accessed September 22, 2006.
16
Brown SA, Garcia AA, Kouzekanani K,
Hanis CA. Culturally competent diabetes selfmanagement
education
for
Mexican

8

TABLE 1
AHCCCS CLINICAL QUALITY PERFORMANCE MEASURES FOR DIABETES
Annual HbA1c Tests, by ALTCS Contractor
Measurement Period: October 1, 2004, through September 30, 2005

Contractor
Pinal/Gila County LTC *

Cochise Health Systems *

Mercy Care LTC *

Pima Health System LTC

Evercare Select

Yavapai County LTC

TOTAL

Included
Cases

Total Receiving
HbA1c Test

Percent Receiving
HbA1c Test

112

101

90.2%

102

89

87.3%

97

77

79.4%

86

76

88.4%

271

209

77.1%

229

176

76.9%

231

163

70.6%

212

160

75.5%

215

149

69.3%

184

112

60.9%

93

63

67.7%

89

65

73.0%

1019

762

74.8%

902

678

75.2%

Shaded rows show results of the previous measurement period, Oct. 1, 2003, through Sept. 30, 2004.
* Indicates that the Contractor met the AHCCCS Minimum Performance Standard.

9

Relative Percent
Change

Significance
Level

3.4%

p=.498

-10.2%

p=.101

0.3%

p=.944

-6.5%

p=.245

13.9%

p=.078

-7.2%

p=.435

-0.5%

p=.845

FIGURE 1
Annual Hb A1c Testing
Current Measurement Period: Oct. 1, 2004, through Sept. 30, 2005
100%

90%
Minimum Performance Standard

80%

70%

Percent

60%

50%

40%

30%

20%

10%

0%
Cochise Health
Systems

Evercare Select

Mercy Care LTC

Pima Health
System LTC

Current Measurement

10

Pinal/Gila County
LTC

Previous Measurement

Yavapai County
LTC

TOTAL

TABLE 2
AHCCCS CLINICAL QUALITY PERFORMANCE MEASURES FOR DIABETES
Biennial Lipid Screening, by ALTCS Contractor
Measurement Period: October 1, 2004, through September 30, 2005

Contractor
Pinal/Gila County LTC *

Mercy Care LTC *

Cochise Health Systems *

Pima Health System LTC

Evercare Select

Yavapai County LTC

TOTAL

Total Receiving
Included Cases Fasting Lipid Profile

Percent Receiving Relative Percent
Fasting Lipid Profile
Change

112

101

90.2%

102

83

81.4%

271

213

78.6%

229

161

70.3%

97

76

78.4%

86

60

69.8%

231

174

75.3%

212

157

74.1%

215

143

66.5%

184

117

63.6%

93

43

46.2%

89

61

68.5%

1019

750

73.6%

902

639

70.8%

Shaded rows show results of the previous measurement period, Oct. 1, 2003, through Sept. 30, 2004.
* Indicates that the Contractor met the AHCCCS Minimum Performance Standard.
Significance level in bold indicates a statistically significant change from the previous measurement.

11

Significance
Level

10.8%

p=.064

11.8%

p=.033

12.3%

p=.185

1.7%

p=.759

4.6%

p=.541

-32.5%

p=.002

3.9%

p=.177

FIGURE 2
Biennial Lipid Test
Current Measurement Period: Oct. 1, 2004, through Sept. 30, 2005
100%

90%
Minimum Performance Standard

80%

70%

Percent

60%

50%

40%

30%

20%

10%

0%
Cochise Health
Systems *

Evercare Select

Mercy Care LTC *

Pima Health
System LTC

Current Measurement

12

Pinal/Gila County
LTC *

Yavapai County
LTC

Previous Measurement

TOTAL

TABLE 3
AHCCCS CLINICAL QUALITY PERFORMANCE MEASURES FOR DIABETES
Biennial Retinal Exams, by ALTCS Contractor
Measurement Period: October 1, 2004, through September 30, 2005

Contractor
Evercare Select *

Pinal/Gila County LTC *

Cochise Health Systems *

Pima Health System LTC *

Yavapai County LTC *

Mercy Care LTC *

TOTAL

Percent
Total Receiving Receiving Retinal
Retinal Exam
Exam

Included
Cases
215

184

85.6%

184

93

50.5%

112

95

84.8%

102

75

73.5%

97

66

68.0%

86

42

48.8%

231

143

61.9%

212

66

31.1%

93

51

54.8%

89

63

70.8%

271

140

51.7%

229

122

53.3%

1019

679

66.6%

902

461

51.1%

Relative
Percent
Change

Shaded rows show results of the previous measurement period, Oct. 1, 2003, through Sept. 30, 2004.
* Indicates that the Contractor met the AHCCCS Minimum Performance Standard.
Significance level in bold indicates a statistically significant change from the previous measurement.

13

Significance
Level

69.3%

p<.001

15.4%

p=.041

39.3%

p=.008

98.8%

p<.001

-22.5%

p=.026

-3.0%

p=.719

30.4%

p<.001

FIGURE 3
Biennial Retinal Exam
Current Measurement Period: Oct. 1, 2004, through Sept. 30, 2005

90%
80%
70%
Minimum Performance Standard

Percent

60%
50%
40%
30%
20%
10%
0%
Cochise Health Evercare Select Mercy Care LTC Pima Health
Systems *
*
*
System LTC *
Current Measurement

14

Pinal/Gila
County LTC *

Previous Measurement

Yavapai County
LTC *

TOTAL

METHODOLOGY
Arizona Health Care Cost Containment System (AHCCCS)
Arizona Long Term Care system (ALTCS)
DIABETES PERFORMANCE MEASURES
Measurement Period: October 1, 2004, through September 30, 2005

Background
Diabetes is the sixth leading cause of death among Americans, contributing to more than
200,000 deaths each year. The United States Department of Health and Human Services
(DHHS) estimates that 18 million Americans age 20 years and older have diabetes,
accounting for 8.7 percent of all people in this age group.1,2
According to DHHS estimates, approximately 244,000 Arizona adults had a diagnosis of
diabetes in 2002.3
Diabetes is becoming more common in the United States. Since 1991, the number of adult
Americans with diabetes has increased by about 60 percent.2 The prevalence of diabetes also
has increased in Arizona during that time. In 1990, the state ranked among those with a
prevalence of diabetes of less than 4 percent of adults. In 2002, Arizona ranked among those
states with a prevalence of between 6 and 8 percent.4
Direct and indirect costs associated with diabetes in the United States, including lost
2,5
productivity, were estimated to be $132 billion in 2002. Diabetes is the leading cause of
end-stage kidney disease and new cases of blindness among U.S. adults ages 20 to 74 years. It
is responsible for more than 60 percent of nontraumatic lower-limb amputations. Other
complications include heart disease, stroke, high blood pressure, nervous system disease and
dental disease.1 About 3.5 million hospitalizations each year are associated with diabetes.6
In the U.S., Hispanics, blacks, American Indians and Alaska natives are two to three times
more likely to have diabetes than non-Hispanic whites. The prevalence of diabetes also is
higher among older Americans: nearly 20 percent of all people 65 and older have diabetes.2
Purpose
The purpose of the AHCCCS performance measures for diabetes care is to monitor and
improve the percentage of ALTCS members with diabetes who receive diagnostic and
preventive services, in order to facilitate the medical care and self management necessary to
minimize complications. This report summarizes the performance of ALTCS Contractors for
these measures.
Measurement. Periods
October 1, 2004, through September 30, 2005
Study Questions
1. What is the prevalence of diabetes among the Arizona Long Term Care System
(ALTCS) members who are no less than 18 years of age and no greater than 75
years of age as of September 30, 2005?

i

2. What is the number and percent, overall, and by Contractor, of members enrolled
with (ALTCS) Contractors who meet the sample frame criteria and who had an
annual HbA1c blood test completed between October 1, 2004 and September 30,
2005?
3. What is the number and percent, overall, and by Contractor, of members enrolled
with ALTCS Contractors who meet the sample frame criteria and who had a
biennial Fasting Lipid Profile (Cholesterol, HDL and LDL) completed between
October 1, 2004 and September 30, 2005?
4. What is the number and percent, overall, and by Contractor, of members enrolled
with ALTCS Contractors who meet the sample frame criteria and had a biennial
Retinal exam completed between October 1, 2004 and September 30, 2005?
Population
This study will include AHCCCS members diagnosed with diabetes, as defined by HEDIS®
2005. Members may be identified as diabetic during the measurement year or twelve months
prior (October 1, 2003, through September 30, 2005).
Population Exclusions
The following members will be excluded from this study:
• Members less than 18 years of age.
• Members greater than 75 years of age.
• Members with Prior Period Coverage
• Members not enrolled the last day of the study period
• Members with a gap in coverage greater than 31 days
• Members with steroid induced diabetes and gestational diabetes
• Members with a diagnosis of polycystic ovaries who do not have two face-to-face
encounters with the diagnosis of diabetes in any setting during the measurement year or prior
year
• Tribal and Fee for Service members will be excluded due to the inability to accurately
collect complete data on these populations. Often these members seek medical care outside of
the AHCCCS system; therefore, data would not be available from AHCCCS administrative
data.
Population Stratification
The population will be stratified by:
• Program type (ALTCS*)
• Contractor
* E/PD and VD populations for each Contractor will be combined before stratifying
Sample Frame
The sample frame will consist of members 18 through 75 years of age as of September 30,
2005, who were continuously enrolled during the measurement period, with no more than one
gap in enrollment of up to 31 days, and diagnosed with type 1 or type 2 diabetes.
• Prior Period Coverage (PPC) will be considered a break in enrollment.
• A change of county service area with the same Contractor, without a gap in enrollment,
will not be considered a break in enrollment.

ii

Sample Selection
The sample frame will be identified through enrollment, claims and encounter records using
the stated criteria. A statistical software program will be used to select a representative,
random sample, using a 95-percent confidence level and a confidence interval of +/-5 percent.
Based on prior studies, an over sampling rate of 10 percent will be utilized.
Identification of Members with Diabetes
Members with diabetes will be identified, according to HEDIS 2005 specifications, by one of
the following methods:
Pharmacy Data
• National Drug Code (NDC) list
available at: http://www.ncqa.org/Programs/HEDIS/hedis2005NDCFinallists.htm
OR
Diagnosis Codes
• 250
– Diabetes mellitus
• 357.2 – Polyneuropathy in diabetes
• 362.0 – Diabetic retinopathy
• 366.41 – Central serous retinopathy
• 648.0 – Diabetes
AND
Two face-to-face encounters with different dates of service in an ambulatory or non-acute
inpatient setting, or one face-to-face encounter in an acute inpatient or emergency room
setting during the measurement year, or the year prior to the measurement year, with a
diagnosis of diabetes as specified above. See Appendix A for codes to identify encounters.
Indicators
HbA1c testing
This indicator measures whether selected members received one or more HbA1c tests during
the measurement period, identified through either administrative data or medical record
review. A member is considered to have had an HbA1c test if:
• a claim or encounter, using codes listed in the following table or an automated laboratory
record with a service date during the measurement period was found for the member
Codes to Identify HbA1c Tests
CPT Code
LOINC
83036
4548-4, 4549-2, 17855-8, 17856-6
or
•

There was documentation in the member’s medical record (at a minimum, a note or lab
result record) indicating the date an HbA1c test was performed. The following notations
count toward this indicator:
o glycated hemoglobin

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o
o
o
o
o

glycosylated hemoglobin
A1c
HbA1c
Hemoglobin A1c
HgbA1c

Fasting Lipid Profile
This indicator measures whether selected members received one or more LDL-C tests during
the measurement period or year prior to measurement period, identified through either
administrative data or medical record review. A member is considered to have had an LDL-C
test if:
• A claim or encounter, using codes listed in the following table or an automated laboratory
record with a service date during the measurement period that was found for the member,
Codes to Identify LDL-C Screening
CPT Code
LOINC
80061, 83715, 83716, 83721 2089-1, 12773-8, 13457-7, 18261-8, 18262-6, 22748-8,
24331-1
or
•

There was documentation in the member’s medical record (at a minimum, a note or lab
result record) indicating the date a fasting Lipid Profile test was performed and the result.

Retinal Exam
This indicator measures an eye screening for diabetic retinal disease. It includes those
diabetics who had a retinal or dilated eye exam by an eye care professional (optometrist or
ophthalmologist) within the measurement period.
• Documented through either administrative data (using claim/encounter with one of the
CPT or ICD-9 codes used for identification of eye exams) or medical record review.
Codes to Identify Eye Exams:
CPT Codes
67101, 67105, 67107-67108, 67110,
67145, 67208, 67210, 67218, 67227,
92004, 92012, 92014, 92018, 92019,
92230, 92235, 92240, 92250, 92260,
99205, 99213 - 99215, 99242-99245

ICD-9-CM Codes
67112, 67141, 14.1-14.5, 14.9,
67228, 92002, 95.11, 95.12, 95.16
92225, 92226,
92287, 99203-

•

95.02-95.04,

A negative retinal exam (an examination by an eye-care professional with no evidence of
retinopathy) is allowed to be counted toward the numerator performed in the year prior to
October 1, 2004 through September 30, 2005, if the member meets both of the following
criteria:
o The member was not prescribed or dispensed insulin during the measurement year.
o The member’s most recent HbA1c level (performed during the measurement
period) is <8.0%.

iv

Denominator
1. The total number of sample members enrolled with ALTCS Contractors during the
measurement period.
Numerators
1. The number of members that met the sample frame criteria
2. The number of ALTCS EP/D members who had one or more Hb A1c tests during the
measurement period
3. The number of ALTCS EP/D members who had a fasting lipid profile during the
measurement period or the preceding year
4. The number of ALTCS EP/D members who had a retinal exam during the measurement
period or the preceding year
Confidentiality Plan
AHCCCS continues to work in collaboration with Contractors to maintain compliance with
the Health Insurance Portability and Accountability Act (HIPAA) requirements. The Data
Analysis and Research (DA&R) Unit maintains the following security and confidentiality
protocols:
• To prevent unauthorized access, the sample member file is maintained on a secure,
password-protected computer, by the DA&R project lead.
• Only AHCCCS employees who analyze data for this project will have access to study
data.
• All employees and Contractors are required to sign a confidentiality agreement.
• Requested data are used only for the purpose of performing health care operations,
oversight of the health care system, or research.
• Only the minimum amount of necessary information to complete the project is sent to and
returned from Contractors.
• Sample files given to Contractors are tracked to ensure that all records are returned.
• Member names are never identified or used in reporting.
• Upon completion, all study information is removed from the computer and placed on a
compact disk, and stored in a secure location.
Data Sources
• Encounters, claims and pharmacy data (Form C) will be used to identify the population.
• AHCCCS has worked in collaboration with laboratories to establish a direct data links
between Contractors and laboratories in their networks. These laboratories have the capability
to electronically download member lab results directly into a Contractor’s data information
system. Contractors may collect data directly from their data information systems.
• When administrative or laboratory data is not available, data will be collected from
members’ medical or case management records.
Data Collection Process
• When the final population file is received from the AHCCCS Information Services
Division, the sample population will be selected by the DA&R Unit.
• Applicable services from administrative data will paired with members selected for the
study.
• Members found not to have complete data will be sent to Contractors in an electronic data
file.

v

•
•
•

Contractors will collect the required data and enter it on the electronic file.
The electronic data file will then be returned to AHCCCS.
AHCCCS will require Contractors to submit laboratory records, pertinent medical/case
management record(s), electronic data directly transmitted by laboratories, or claims data to
verify services that were provided.
Quality Assurance Process
• Contractors will be instructed in use of the data collection methods, sample file layout and
timelines for data collection.
• Contractors will receive written instructions for data collection, in addition to AHCCCS
resource and contact information for assistance.
• AHCCCS will verify that all records have been returned. The distribution to Contractors
and return of sample files will be monitored by the DA&R Unit.
• AHCCCS will require Contractors to submit documentation of medical records, case
management notes, and/or laboratory data to verify services that were provided.
Data Validation
• To verify that an annual HbA1c test, Biennial Fasting Lipid Profile tests and an annual
Retinal examination were performed, Contractors must submit any one of the following for
each member identified as receiving indicator services: laboratory records, pertinent medical
or case management record(s), or information extracted from direct transmission of laboratory
data.
• This documentation must contain the confirmation of examination being performed and
date of service. Thus, the documentation also will validate that all tests for each indicator
were performed during the measurement period. If no documentation of an indicator
examination is available, but the Contractor has evidence of a claim paid for the tests
(individual CPT and/or ICD-9 codes), the Contractor should submit verification of the
administrative data.
• A double-blind validation may be performed by AHCCCS, matching the medical/case
management record or laboratory data with data on the Contractor’s electronic file.
Limitations
• A large portion of the ALTCS population also is covered by Medicare and seeks services
outside the AHCCCS provider system. Because Medicare is the primary payer for Medicare
beneficiaries, AHCCCS does not have the ability to collect information on services provided
to members outside the AHCCCS system. Thus, some members with diabetes may not be
identified for inclusion in this study.
Deviations from Previous Methodology
®
• Codes to identify diabetic members were updated in HEDIS 2005, including:
o Remove Glucophage/metformin from table of prescriptions that identify
diabetics using pharmacy data. Diabetic members on these medications are
identified through diagnosis coding only.
o Remove glychohemoglobin from the HbA1c screening and control indicators.
o Delete CPT codes 99288 from table that identifies acute inpatient/ emergency
department visits.
o Add UB-92 revenue code 19X to the outpatient/non-acute codes.
o Add new table identifying HbA1c testing

vi

o Add CPT codes 99203 and 99213 to table that identifies eye exams.
o Add LOINC (Logical Observation Identifiers Names and Codes) to tables that
identify HbA1c, LDL-C, Microalbuminuria and Macroalbuminuria tests.
o Add ICD-9CM code 251.8 to table that identifies steroid-induced diabetes.
Analysis Plan
• The denominator will be divided by the numerator to determine the percentage of
compliance with each indicator. The rates will be analyzed and reported overall and by
ALTCS Contractor.
• Variability of distribution will be calculated by range and standard deviation. Any
Contractor with results more than two standard deviations from the mean will be identified,
and the reason ascertained if possible. To avoid skewed and misleading conclusions, any
such Contractor may be excluded from selected charts and graphs. Clear documentation in
the report will caveat any Contractor exclusions and the reasons for exclusion.
Comparative Analysis
• Prior studies will be compared to the current results.
• The results of this study will be compared to the results of other state Medicaid programs
as reported by the National Committee for Quality Assurance (NCQA), Minimal Performance
Standard and AHCCCS Goal.
• Individual Contractors will be compared to each other and to the statewide average.
• All other stratifications as deemed appropriate (i.e. age, gender, ethnicity) will be
compared with each other.
Report Format
• The report will include the methodology used, narrative summary of analysis findings,
limitations and recommendations
• Findings will be displayed in appropriate charts, tables and/or graphs, with results reported
by individual Contractor, program type, and statewide aggregate.
• The comprehensive findings will be presented in a manner that will allow for easy
interpretation of the data by evaluators at the federal, state, and Contractor levels.
• Results will be reported on the AHCCCS website and will be sent to the Centers for
Medicare and Medicaid Services (CMS).
Definitions
Statistically Significant: A finding is described as statistically significant, when it can be
demonstrated that the probability of obtaining such a difference by chance only is relatively
low. It is customary to describe one's finding as statistically significant, when the obtained
result is among those that (theoretically) would occur no more than 5 out of 100 times, p<=
.05, or occur no more than 1 out of 100 times, p<=. 01, when the only factors operating are
the chance variations that occur whenever random samples are drawn. It is important to note
that a finding may be statistically significant but may not be clinically or financially
significant.
The statistically significant value is calculated using the Pearson chi-square test.
parameters used are:
Degree of Freedom =1
Statistical Significance Level p<= .05

vii

The

TECHNICAL SPECIFICATIONS
Diagnosis
May be identified by pharmacy data, claims or encounters
Pharmacy Data:
List of National Drug Codes (NDC) available at:
http://www.ncqa.org/Programs/HEDIS/hedis2005NDCFinallists.htm
OR
Claims/Encounter Data:
Two face-to-face encounters with different dates of service in an ambulatory setting or
non-acute inpatient setting, or one face-to-face encounter in an acute inpatient
emergency room setting during the measurement year or year prior with a diagnosis of
diabetes. A diagnosis of diabetes will be determined by utilizing the following codes:
Description
Diabetes
diagnosis
Outpatient/nonacute inpatient

Acute
inpatient/ED

ICD-9-CM Codes
250, 357.2, 362.0,
366.41, 648.0
19x, 456, 49X-53X,
55X-59X, 65X, 66X,
76X, 77X, 82X-85X,
88X, 92X, 94X, 96X,
972-979, 982-986, 988,
989

CPT Codes

DRG
294,295

92002-92014, 99201-99205,
99211-99215, 99217-99220,
99241-99245, 99271-99275,
99301-99303, 99311-99313,
99321-99323, 99331-99333,
99341-99355, 99384-99387,
99394-99397, 99401-99404,
99411, 99412, 99420-99429,
99499
10X-16X,
20X-22X, 99221-99223, 99231-99233,
450, 451, 452, 459, 99238-99239, 99251-99255,
99261-99263, 99281-99285,
72X, 80X, 981, 987
99291-99292, 99356-99357

Criteria for HbA1c
• One (or more) HbA1c test(s) conducted during the measurement year, denoted by codes
listed in the following table:
Codes to Identify HbA1c Tests
CPT Code
LOINC
83036
4548-4, 4549-2, 17855-8, 17856-6

viii

Criteria for Eye Exam
• A retinal exam performed during the measurement year or the preceding year
Codes to Identify Eye Exams:
CPT Codes
67101, 67105, 67107-67108, 67110,
67145, 67208, 67210, 67218, 67227,
92004, 92012, 92014, 92018, 92019,
92230, 92235, 92240, 92250, 92260,
99205, 99213 - 99215, 99242-99245

ICD-9-CM Codes
67112, 67141, 14.1-14.5, 14.9, 95.02-95.04,
67228, 92002, 95.11, 95.12, 95.16
92225, 92226,
92287,99203 -

Criteria for Lipid (LDL-C) Screening
• An LDL-C test done during the measurement year or year prior to the measurement year
denoted by the following codes:
Codes to Identify LDL-C Screening
CPT Codes
LOINC
80061, 83715, 83716, 83721
2089-1, 12773-8, 13457-7, 18261-8, 18262-6, 22748-8,
24331-1
Exclusions
Description
Steroid Induced Diabetes
Polycystic Ovaries
Gestational Diabetes

ICD-9-CM Codes
251.8, 962.0
256.4
648.8

ix