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

PERFORMANCE MEASURES FOR DIABETES CARE
Measurement Period: October 1, 2007, through September 30, 2008
Prepared by the Division of Health Care Management
November 2009

Thomas J. Betlach
Director, AHCCCS

Arizona Health Care Cost Containment System (AHCCCS)
Arizona Long Term Care System (ALTCS)
PERFORMANCE MEASURES FOR DIABETES CARE
For the Measurement Period October 1, 2007, through September 30, 2008
INTRODUCTION

1

SIGNIFICANCE OF THE MEASURES

2

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

4
4
4
4
4
4
4
5
5

RESULTS
Hb A1c Testing ..........................................................................................................
Lipid Profiles .............................................................................................................
Eye Examinations ......................................................................................................
Results by Race/Ethnicity ..........................................................................................
Results by County Type .............................................................................................

5
6
6
6
6

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

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7
7
8

REFERENCES

8

TABLES AND FIGURES
APPENDIX: METHODOLOGY AND TECHNICAL SPECIFICATIONS

10

Arizona Health Care Cost Containment System (AHCCCS)
Arizona Long Term Care System (ALTCS)
PERFORMANCE MEASURES FOR DIABETES CARE
For the Measurement Period October 1, 2007, through September 30, 2008

INTRODUCTION
the number of Americans with diabetes
increased from 5.6 million to 15.8 million.3
The prevalence of diabetes in Arizona also
increased during that time.4

Diabetes is a serious health problem that is
growing rapidly in the United States. More
than 23 million Americans age 20 years and
older, or 10.7 percent of all people in this
age group, have diabetes, according to an
estimate by the federal Centers for Disease
Control and Prevention (CDC). About 1.6
million new cases of diabetes were
diagnosed among U.S. adults in 2007.1

A sedentary lifestyle and a dramatic rise of
obesity in the U.S. population are
contributing to the increase in this costly and
potentially
deadly
disease.
Surveys
conducted in recent years have found that
about 60 percent of American adults are
either overweight or obese.5,6 Another study
found that nearly half of obese persons have
type 2 diabetes.7

In Arizona, an estimated 375,000 adults had
diabetes in 2006, and another 125,000 were
living with undiagnosed diabetes. Diabetesrelated hospitalizations in Arizona nonfederal facilities accounted for more than
$3.5 billion in 2006, with an average length
of stay of 5 days.2

Hispanics, Blacks, American Indians and
Alaska Natives are approximately twice as
likely to have diabetes than non-Hispanic
Whites in the U.S. The prevalence of
diabetes also is higher among older
Americans – about 20 percent of all people
60 and older have diabetes – as well as
among people with low socioeconomic
status and those covered by Medicaid. 1,3,4

Figure 1. Prevalence of Diagnosed Diabetes:
Adults in Arizona and the U.S., 1994 –2006

Total U.S. expenditures related to diabetes
are approximately $174 billion a year ― a
32 percent increase since 2002 ― according
to a study commissioned by the American
Diabetes Association. That includes $116
billion in direct medical costs and another
$58 billion in indirect costs because of
missed work days or other losses in
productivity.8
At
least
4
million
hospitalizations annually in the U.S. are
associated with diabetes.9

Source: Behavior Risk Factor Surveillance System, Centers
for Disease Control & Prevention

The number of people in the United States
with diagnosed diabetes has nearly tripled in
the last 25 years. From 1980 through 2005,

1

members. The measures evaluate the percent
of ALTCS elderly and physically disabled
(E/PD) members with diabetes who receive
certain clinical services to detect and prevent
or reduce complications.

Diabetes with comorbidities (diseases that
coexist and are often related to a primary
condition) was the second-most prevalent
diagnosis affecting AHCCCS members
enrolled with the Arizona Long Term Care
System (ALTCS) in the contract year ending
Sept. 30, 2007. ALTCS members with type
II diabetes accounted for more than $23
million in medical costs in an earlier twoyear span (July 2003 to June 2005).

Results of the measurement are used to
determine whether these managed care plans
(known as Contractors), are meeting
Performance Standards specified in their
contracts. This report summarizes these
results and compares Contractors’ rates to
performance standards and national means
for managed care plans.

The purpose of this study is to monitor
performance of managed care plans
contracted to provide services to ALTCS

SIGNIFICANCE OF THE MEASURES
As with many diseases, other conditions
(known as comorbid conditions) may be
present. The increased prevalence of
hyperlipidemia (high cholesterol levels)
found with type 2 diabetes contributes to
higher rates of cardiovascular disease among
diabetics.

With diabetes, sustained high blood sugars
result in damage to very small blood vessels
throughout the body. One of these
“microvascular”
complications
is
retinopathy (damage to the retina of the
eye), which causes 12,000 to 24,000 new
cases of blindness each year. Diabetes also
is the leading cause of end stage renal
(kidney) disease, or ESRD, and is
responsible for more than half of
nontraumatic lower-limb amputations.1

• 2 in 3 people with diabetes die of
heart disease or stroke
• Diabetes is the #1 cause of adult
blindness

Diabetes also results in “macrovascular”
complications, including coronary and
peripheral artery disease. In fact, heart
disease and stroke account for about 65
percent of deaths among people with
diabetes.10

• Diabetes is the #1 cause of
kidney failure
Diabetes: The Numbers
National Diabetes Education Program

Patients with diabetes also have worse
outcomes with acute illness. For example,
diabetics who are hospitalized for trauma
have longer stays in the intensive care unit
and more complications than people who do
not have diabetes.11

In addition, up to 70 percent of people with
diabetes have mild to severe forms of
neuropathy (nerve damage), including
impaired sensation or pain in the feet or
hands, carpal tunnel syndrome and motor
deficits.

2

Despite its potentially deadly effects,
diabetes can be controlled. Many
complications of the disease can be
prevented or reduced with early detection,
improved care and better education of
patients in self-management techniques.1,12

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.13,14 Control of cholesterol and
lipids
can
reduce
cardiovascular
complications by 20 to 50 percent.3

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.

A fasting lipid profile is performed to
measure total cholesterol (TC), high-density
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
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.

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. 3,14 Ten-year post-trial
monitoring from one of these studies, the
landmark United Kingdom Prospective
Diabetes Study (UKPDS), indicates that a
strategy of early and intensive glucose
lowering has lasting, significant effects – not
only on major diabetes end points, such eye
and kidney disease – but also on the risk of
heart attack and other causes of mortality.15

However, data compiled by the Arizona
Department of Health Services (ADHS)
indicate that many diabetic patients in the
state are not getting the tests they need. In its
2008 annual report of diabetes indicators,
ADHS reported that only 70 percent of
Arizonans with diabetes received an Hb A1c
test during the preceding year, 41 percent
had a lipid screening performed, and 47.6
percent had a dilated retinal exam.2

STUDY METHODS
The Arizona Health Care Cost Containment
System (AHCCCS) used Healthcare
Effectiveness Data and Information Set
(HEDIS) 2009 specifications for this
measurement. Developed and maintained by
the National Committee for Quality
Assurance (NCQA), HEDIS is a widely
adopted and reliable methodology that

allows for comparisons with
Medicaid health plan averages.

national

AHCCCS has selected three of the HEDIS
indicators of comprehensive diabetes care
for measurement of Contractor performance:
Hb A1c testing, lipid screening, and retinal
(eye) exams.

3

sample of members was selected and initial
service data were collected.

Population
The population included elderly and
physically disabled (E/PD) members
enrolled with ALTCS managed care plans
who had diagnoses of type 1 or type 2
diabetes in the measurement period or the
year prior to the measurement period.
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).

When specific services within the
measurement period 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
provided
by
AHCCCS,
Contractors
collected additional data from medical
records and claims systems. Additional
service information was entered on the
electronic tool by Contractor staff, according
to detailed instructions from AHCCCS.

For example, a member was identified for
the study if he or she had a face-to-face
encounter with a medical provider and the
associated claim included a diagnosis of
diabetes. A member also may be identified
as diabetic when dispensed insulin or other
certain types of drugs used to treat diabetes.

Data Quality and Reliability
AHCCCS conducts validation studies to
evaluate the completeness of encounter data,
compared with the corresponding medical
records. The two most recent annual studies
of encounters submitted by ALTCS E/PD
Contractors show encounter-omission rates
of less than 5 percent for each year.

Measurement Period
The measurement period for this study was
the AHCCCS contract year from October 1,
2007, through September 30, 2008.

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. Medicare providers may bill
AHCCCS health plans for copayments for
their members. However, if they do not bill
for copayments for these services, AHCCCS
will not have complete encounter data. Thus,
additional data is collected by Contractors
from medical records. In order to document
the reliability of data collected outside of the
AHCCCS encounter system, Contractors
were required to submit copies of the
appropriate sections of medical records or
documentation from their claims systems.

Sample Frame
The sample frame consisted of E/PD
members who were:
•
ages 18 through 75 years as of
September 30, 2008,
•
continuously enrolled with one ALTCS
Contractor for at least 11 member months
during the measurement period, and
•
enrolled with that Contractor on
September 30, 2008.
Data Sources
The primary data sources were recipient,
claim/encounter, and medical record data.
Data Collection
Recipient and encounter data are stored in
the AHCCCS Prepaid Medical Management
Information System (PMMIS). These data
were loaded into the AHCCCS Decision
Support System (ADDS), from which a

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

4

goals were established in 2006, based on
national HEDIS benchmarks.

Lipid (LDL-C) profile — This indicator
measured the percent of members who had
one or more fasting lipid profiles during the
measurement year.
•

AHCCCS Performance Standards

Retinal examinations — This indicator
measured an eye screening for diabetic
retinal disease with a retinal or dilated eye
exam by an eye-care professional
(optometrist or ophthalmologist) within the
measurement year. A negative retinal exam
(no evidence of retinopathy) by an eye-care
professional in the year prior to the
measurement year also counts toward the
numerator for this measure.
•

Measure

MPS

Goal

Hb A1c testing

80%

89%

Lipid screening

72%

91%

Retinal exams

60%

68%

National Benchmarks
NCQA reports national means (averages) for
these measures, based on data submitted by
managed care plans. The HEDIS 2008
national means for Medicaid plans, as
reported by NCQA, are:

Performance Measure Goals
AHCCCS has established a Minimum
Performance Standard (MPS) for each
measure that ALTCS Contractors must
meet. If they do not meet the MPS for any
measure, they must implement a Corrective
Action Plan to bring the rate up to the
contractual standard and may face a
financial sanction if they fail to show
improvement.

HEDIS National Means
Measure

Medicaid

Commercial

Hb A1c testing

77.4%

88.1%

Lipid screening

70.9%

83.9%

Retinal exams

50.1%

55.0%

The current national means are based on the
same methodology employed by AHCCCS
for this measurement and are useful for
comparisons with AHCCCS results.

AHCCCS also has established Goals that
Contractors should strive to meet if they are
already meeting minimum standards. These

RESULTS
The measurement included 1,389 sample
members who were enrolled with eight longterm care
Contractors
during
the
measurement period. Results for each
measure were analyzed by individual
Contractor, by members’ race/ethnicity and
by rural vs. urban areas. Changes in
Contractor and overall rates from the
previous measurement period are described
as increases or decreases when analysis
using the Pearson chi-square test yields a
statistically significant value (p<.05); that is,
the probability of obtaining such a

difference by chance only is relatively low.
Hb A1c Testing
The overall rate of Hb A1c testing during the
measurement year was 78.9 percent,
compared with the previous rate of 80.1
percent (Table 1). The change was not
statistically significant (p=.439). Rates by
Contractor ranged from 63.6 percent to 88.7
percent. One Contractor showed a
statistically significant increase in its rate
and one showed a statistically significant
decrease.

5

Medicaid plans and four Contractors’ rates
exceeded the national commercial mean.
The AHCCCS overall rate exceeded the
HEDIS national means for both Medicaid
and commercial health plans.

Five Contractors exceeded the AHCCCS
Minimum Performance Standard (MPS) for
this measure (Figure 1). Six Contractors
exceeded the Medicaid mean and one
surpassed the commercial mean. The
AHCCCS overall rate exceeded the HEDIS
national mean for Medicaid health plans.

AHCCCS overall rates for
all three measures met or exceeded
the national Medicaid means

Lipid (LDL-C) Profiles
The overall rate of members who had an
LDL-C test or fasting lipid profile during the
measurement year was 70.9 percent (Table
2), compared with 72.0 percent in the
previous measurement. The change was not
statistically significant (p=.532).

Results by Race/Ethnicity
For all measures, there were no significant
differences in rates for members who
identified themselves as Hispanic, Native
American or Black, compared with nonHispanic White members. Relative rates
were as follows:

Contractor rates ranged from 52.3 percent to
85.7 percent. Two Contractors showed
significant increases and two showed
significant decreases.

Rates by Race/Ethnicity, CYE 2007

Five Contractors exceeded the MPS, as well
as the AHCCCS Goal (Figure 2). These
same five Contractors also exceeded the
HEDIS national Medicaid mean and one
surpassed the national commercial mean.
The AHCCCS overall rate equaled the
national mean for Medicaid health plans.

Hb A1c

Lipid

Retinal

White

79.1%

72.1%

58.8%

Hispanic

78.7%

67.5%

63.6%

Black

74.7%

63.9%

72.3%

Native American

82.1%

75.0%

60.7%

Other/Unknown

79.9%

76.6%

49.5%

1

2

Eye Examinations
The overall rate of members who had a
dilated eye (retinal) examination in the
measurement year or a negative exam in the
previous year was 59.8 percent, compared
with 57.1 percent in the previous
measurement (Table 3). The change was not
statistically significant (p=.157).

1 Non-Hispanic Whites were used as the reference group for
analyzing whether disparities in use of services exist based
on race/ethnicity.
2 Results for Native Americans should be interpreted with
caution, since there were only 17 members in this category.

Results by County Type
There were significant differences in rates
between members residing in rural and
urban counties for two of the measures.
Members living in urban counties were more
likely to have an Hb A1c test during the year,
at 83.6 percent, than those in rural counties,
at 73.0 percent (p< .001). Members in urban
counties also were more likely to have a
lipid screening during the year, at 76.0
percent, compared with those living in rural
counties, at 63.8 percent (p< .001)

Rates by Contractor ranged from 31.8
percent to 72.4 percent. Two Contractors
showed significant increases and none
showed significant decreases.
Four Contractors exceeded the AHCCCS
MPS and three exceeded the Goal for this
measure (Figure 3). In addition, seven
Contractors had rates that surpassed the
most recent HEDIS national means for

6

DISCUSSION
AHCCCS will work with the lowestperforming Contractors to assist and
encourage them to improve rates.

Overall Results
AHCCCS overall rates remained stable for
all three measures. AHCCCS overall rates
for two measures — Hb A1c testing and
eye exams — exceeded the most recent
HEDIS national means for Medicaid
managed care plans, and the rate for lipid
screening equaled the national average.
The AHCCCS overall rate for eye exams
also exceeded the most recent HEDIS
commercial mean.

Quality Improvement Efforts
AHCCCS Contractors have utilized a
variety of strategies to improve care of
diabetic members. These include intensive
member
education,
monitoring
of
members’ test status and follow up by case
managers and nurses; distributing to
primary care physicians (PCPs) practice
guidelines and other tools, such as a
diabetic flow sheet to help track tests that
must be performed periodically, and
advising PCPs of diabetic members who
are due or overdue for specific services.

It should be noted that AHCCCS increased
the MPS for Hb A1c testing for this
measurement period, in order to encourage
continued improvement in Contractor
performance.

The interventions that involve PCPs may
be especially effective, since research
shows that, among people with diabetes,
physicians are the primary source of
information about their disease and best
positioned to influence compliance with
self-management
and
receipt
of
recommended
services.7
Contractors
should continue to reinforce with
providers the current clinical standards of
care for members with diabetes.

Contractor Performance
Three Contractors — Evercare Select,
Mercy Care Long Term Care Plan and
Yavapai County Long Term Care — met
the AHCCCS Minimum Performance
Standards for all measures. Mercy Care
has shown strong performance in these
measures, meeting all minimum standards
for the past three years.
All Contractors except Mercy Care have
corrective action plans (CAPs) in place for
at least one of the diabetes measures. Most
of these CAPs were implemented in early
2009, and would not have affected the
current measurement period. However, it
is expected that Contractors will show
improvement in the next measurement
period, based on these CAPs.

In order to assist ALTCS Contractors with
improving their rates for these measures,
AHCCCS has provided health plans with
educational materials and opportunities, as
well as information on successful
strategies for increasing the use of
preventive-care services.

It appears that incomplete data collection
affected results for Pima Health System,
and the Contractor must address this issue
as part of its corrective actions.

Successful strategies used in other
programs include:
•
automated reminders by telephone to
advise patients that they are due for tests;

7

http://www.cdc.gov/nccdphp/aag/pdf/aag_ddt2004.
pdf. Accessed September 22, 2008.
4
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/state/ta
ble15.htm. Accessed September 15, 2008.
5
Davis SN, Perkins JM. Role of the
endocannabinoid system is management of patients
with type 2 diabetes mellitus and cardiovascular
risk factors. Medscape 2008. Available at:
http://www.medscape.com/viewarticle/5722252.
Accessed Apr. 23, 2008.
6
Vega CP. Stress and obesity: Partners in disease.
Medscape 2007. Available at:
http://www.medscape.com/viewprogram/7780.
Accessed Sept. 25, 2009.
7
Public knowledge, perceptions and behavior
regarding diabetes and diabetes prevention: A
societal barometer. Princeton, NJ: Gallup Inc.,
2008. Available at:
http://www.ncdp.com/downloads/FINAL%20PRIN
TED%20REPORT%20WITH%20COVER.pdf.
Accessed July 7, 2008.
8
Devastating toll of diabetes reaches $174 billion
[press release]. Alexandria, VA: American
Diabetes Association; January 23, 2008. Available
at:
http://www.diabetes.org/for-media/prdevastating-toll-of-diabetes-reaches-174-billion012308.jsp .Accessed February 7, 2008.
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/mmwrhtml/rr5
311a1.htm Accessed September 22, 2009.
10
American Diabetes Association. Complications
of diabetes in the United States. Available at:
http://www.diabetes.org/diabetesstatistics/complications.jsp. Accessed July 21,
2008.
11
Barclay L. Trauma patients with diabetes
mellitus have increased hospital morbidity.
Medscape Medical News. July 18, 2007. Available
at: http://www.medscape.com/viewarticle/559964.
Accessed July 25, 2008.
12
American Diabetes Association. Standards of
medical care in diabetes − 2007. Diabetes Care.
2007;
30(S1).
Available
at:
http://care.diabetesjournals.org/cgi/content/full/30/
suppl_1. Accessed April 3, 2007.

frequent nurse follow-up by phone,
especially as part of a case management or
disease management program; and
•
culturally relevant patient education
materials, such as guides on preparing
healthy meals, particularly those that
incorporate traditional foods for specific
ethnic and racial populations.16-21
•

Because depression and other mental
health issues often coexist with diabetes,
Contractors also should ensure that
members receive behavioral health
services as needed to support their abilities
to manage their self-care.
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.
Contractors must maintain an active focus
on member and provider outreach related
to diabetes care, in order to continue
progress toward long-term goals for use of
recommended screenings.
REFERENCES
1

Centers for Disease Control and Prevention.
National diabetes fact sheet: general information
and national estimates on diabetes in the United
States, 2007. Atlanta, GA: U.S. Department of
Health and Human Services, Centers for Disease
Control and Prevention, 2008. Available at:
http://www.diabetes.org/diabetes-statistics.jsp.
Accessed July 27, 2009.
2
Arizona Diabetes Coalition, Surveillance
Committee. Arizona Diabetes Indicators Annual
Report 2008. Arizona Department of Health
Services, Diabetes Prevention and Control
Program. July 2008.
3
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:

8

21

13

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):20112017. Available at:
http://care.diabetesjournals.org/cgi/content/abstract
/29/7. Accessed September 22, 2008.

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/factsheet
s/Prevention/diabetes.htm. Accessed September 22,
2008.
14
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, 2008.
15
Wood S. Ten years later, UKPDS shows
intensive glucose lowering, but not tight BP
control, reduces MI, all-Cause mortality. Medscape
Medical News. Sept. 11, 2008. Available at:
http://www.medscape.com/viewarticle/580370_pri
nt?wwparam=1221691717
Accessed Sept. 17, 2008.
16
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/abstract
/23/4. Accessed Sept. 17, 2008.
17
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/abstract
/full/24/2. Accessed September 22, 2008.
18
Brown SA, Garcia AA, Kouzekanani K, Hanis
CA. Culturally competent diabetes selfmanagement education for Mexican Americans.
Diabetes Care. 2002; 25(2):259-268. Available at:
http://care.diabetesjournals.org/cgi/content/full/25/
2 Accessed September 22, 2008.
19
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/abstract
/full/25/1 Accessed September 22, 2008.
20
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/abstract
/22/12. Accessed September 22, 2008.

For questions or comments about this report,
please contact:
Rochelle Tigner
Quality Improvement Manager
Clinical Quality Management
DHCM, AHCCCS
Rochelle.Tigner@azahcccs.gov

9

TABLE 1
AHCCCS Clinical Quality Performance Measures for Diabetes
Hb A1c TESTS - ALTCS E/PD MEMBERS WITH DIABETES
Current Measurement Period: October 1, 2007, through September 30, 2008

Contractor
Bridgeway Health Solution *
Cochise Health Systems
Evercare Select *
Mercy Care LTC *
Pima Health System LTC
Pinal/Gila County LTC *
Scan Long Term Care
Yavapai County LTC *
TOTAL

Included
Cases

Total Receiving
HbA1c Test

Percent Receiving
HbA1c Test

Relative Percent
Change

Significance
Level

132

106

80.3%

4.4%

p=.543

91

70

76.9%

98

76

77.6%

5.8%

p=.486

105

77

73.3%

250

213

85.2%

-2.3%

p=.517

250

218

87.2%

336

298

88.7%

1.5%

p=.594

332

290

87.3%

237

151

63.7%

-22.8%

p<.001

229

189

82.5%

144

116

80.6%

47.3%

p<.001

117

64

54.7%

107

68

63.6%

12.4%

p=.528

23

13

56.5%
2.7%

p=.737

-1.5%

p=.439

85

68

80.0%

86

67

77.9%

1389

1096

78.9%

1233

988

80.1%

Notes:

* Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard (MPS).
Significance levels in bold face indicate a statistically significant change from the previous measurement.
Results of the previous measurement period (Oct. 1, 2006, through Sept. 30, 2007), are shown in shaded rows

10

Figure 1
Hb A1c TESTS - ALTCS E/PD MEMBERS WITH DIABETES
Current Measurement Period: October 1, 2007, through September 30, 2008
100%
Minimum Performance Standard

80%

60%

40%

20%

0%
Bridgeway
Health
Solution *

Cochise
Health
Systems

Evercare
Select *

Mercy Care Pima Health Pinal/Gila
LTC *
System LTC County LTC
*

Current Measurement

11

Scan Long
Term Care

Previous Measurement

Yavapai
County LTC
*

TOTAL

TABLE 2
AHCCCS Clinical Quality Performance Measures for Diabetes
ANNUAL LIPID PROFILES - ALTCS E/PD MEMBERS WITH DIABETES
Current Measurement Period: October 1, 2007, through September 30, 2008

Contractor
Bridgeway Health Solution *
Cochise Health Systems
Evercare Select *
Mercy Care LTC *
Pima Health System LTC
Pinal/Gila County LTC *
Scan Long Term Care
Yavapai County LTC *
TOTAL

Included
Cases

Total Receiving
Fasting Lipid

Percent Receiving
Fasting Lipid

Relative Percent
Change

Significance
Level

132

97

73.5%

4.5%

p=.605

91

64

70.3%

98

67

68.4%

1.1%

p=.909

105

71

67.6%

250

180

72.0%

-10.9%

p=.021

250

202

80.8%

336

288

85.7%

3.5%

p=.306

332

275

82.8%

237

124

52.3%

-21.7%

p=.001

229

153

66.8%

144

107

74.3%

33.8%

p=.001

117

65

55.6%

107

60

56.1%

17.2%

p=.471

23

11

47.8%

85

62

72.9%

33.5%

p=.013

86

47

54.7%

1389

985

70.9%

-1.5%

p=.532

1233

888

72.0%

Notes:

* Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard (MPS).
Significance levels in bold face indicate a statistically significant change from the previous measurement.
Results of the previous measurement period (Oct. 1, 2006, through Sept. 30, 2007), are shown in shaded rows

12

Figure 2
LIPID PROFILES - ALTCS E/PD MEMBERS WITH DIABETES
Current Measurement Period: October 1, 2007, through September 30, 2008
100%

Minimum Performance Standard
80%

60%

40%

20%

0%
Bridgeway
Health
Solution *

Cochise
Health
Systems

Evercare
Select *

Mercy Care Pima Health Pinal/Gila Scan Long
Yavapai
LTC *
System LTC County LTC Term Care County LTC
*
*

Current Measurement

13

Previous Measurement

TOTAL

TABLE 3
AHCCCS Clinical Quality Performance Measures for Diabetes
RETINAL EXAMS - ALTCS E/PD MEMBERS WITH DIABETES
Current Measurement Period: October 1, 2007, through September 30, 2008

Contractor
Bridgeway Health Solution
Cochise Health Systems *
Evercare Select *
Mercy Care LTC *
Pima Health System LTC
Pinal/Gila County LTC
Scan Long Term Care
Yavapai County LTC *
TOTAL

Included
Cases

Percent
Total Receiving Receiving Retinal Relative Percent
Retinal Exam
Exam
Change

132

67

50.8%

91

39

42.9%

98

69

70.4%

105

80

76.2%

250

181

72.4%

250

147

58.8%

336

229

68.2%

332

224

67.5%

237

121

51.1%

229

115

50.2%

144

77

53.5%

117

44

37.6%

107

34

31.8%

23

6

26.1%

85

53

62.4%

86

49

57.0%

1389

831

59.8%

1233

704

57.1%

18.4%

p=.246

-7.6%

p=.352

23.1%

p=.001

1.0%

p=.850

1.7%

p=.857

42.2%

p=.011

21.8%

p=.592

9.4%

p=.474

4.8%

p=.157

Notes:
* Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard (MPS).
Significance levels in bold face indicate a statistically significant change from the previous measurement.
Results of the previous measurement period (Oct. 1, 2006, through Sept. 30, 2007), are shown in shaded rows

14

Significance
Level

Figure 3
RETINAL EXAMS - ALTCS E/PD MEMBERS WITH DIABETES
Current Measurement Period: October 1, 2007, through September 30, 2008
100%

80%
Minimum Performance Standard
60%

40%

20%

0%
Bridgeway
Health
Solution

Cochise
Health
Systems *

Evercare
Select *

Pima Health Pinal/Gila Mercy Care
System LTC County LTC
LTC *

Current Measurement

15

Previous Measurement

Scan Long
Term Care

Yavapai
County LTC
*

TOTAL

Appendix:
METHODOLOGY
Arizona Health Care Cost Containment System (AHCCCS)
Arizona Long Term Care System (ALTCS)
DIABETES PERFORMANCE MEASURES
Measurement Period: October 1, 2007, through September 30, 2008

Purpose
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.
Measurement Period
October 1, 2007, through September 30, 2008
Study Questions
1. What is the number and percent, overall, and by Contractor, of members enrolled
with ALTCS Contractors who met the sample frame criteria and who had one or
more HbA1c blood tests during the measurement period?
2. What is the number and percent, overall, and by Contractor, of members enrolled
with ALTCS Contractors who met the sample frame criteria and who had at one or
more fasting lipid profiles (cholesterol, high density lipoprotein or HDL and low
density lipoprotein or LDL) during the measurement period?
3. 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 retinal
exam during the measurement period or a negative exam during the preceding
year?
Population
This study includes AHCCCS members diagnosed with diabetes, as defined by HEDIS®
2009. Members may be identified as diabetic during the measurement year or the twelve
months prior to the measurement period.
Population Exclusions
The following members are excluded from this study:
•
Members less than 18 years of age.
•
Members greater than 75 years of age.
•
Members not enrolled the last day of the study period
•
Members with a gap in coverage greater than one month
•
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

i

•

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 are combined before stratifying

Sample Frame
The sample frame consists of members 18 through 75 years of age as of September 30, 2008,
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.
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 2009 specifications, by
pharmacy data (National Drug Code or NDC list) or by specific diagnosis codes. To be
included in the measurement, members must have had 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.
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, according to HEDIS 2009 specifications. 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

ii

Codes to Identify HbA1c Tests
CPT Code
83036, 83037

CPT Category II
3044F, 3045F, 3046F, 3047F

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
o glycosylated hemoglobin
o A1c
o HbA1c
o Hemoglobin A1c
o HgbA1c
Fasting Lipid Profile
This indicator measures whether selected members received one or more LDL-C tests during
the measurement period, identified through either administrative data or medical record
review, according to HEDIS 2009 specifications. 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
80061, 83700, 83701, 83704, 83721

CPT Category II
3048F, 3049F, 3050F

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 was performed and the result.
Retinal Exam
This indicator measures an eye screening for diabetic retinal disease, documented through
either administrative data or medical record review. It includes a retinal or dilated eye exam
by an eye care professional (optometrist or ophthalmologist) within the measurement period
or a negative retinal exam (no evidence of retinopathy) by an eye-care professional in the year
prior to the measurement year. At a minimum, documentation in the medical record must
include:
•
a note or letter from an ophthalmologist, optometrist or other health-care professional
summarizing the date on which the procedure was performed and the results of a retinal
evaluation performed by an eye-care professional
or
•
a chart or photograph of retinal abnormalities. If fundus photography was used in the
exam, there must be documentation in the medical record indicating the date on which the
procedure was performed and evidence that an eye-care professional reviewed the results.
Alternatively, results may be read by a qualified reading center that operates under the
direction of a medical director who is a retinal specialist
iii

or
•

a note, which may be prepared by a primary care provider, indicating the date on which
the procedure was performed, and that an ophthalmoscopic exam was completed by an eyecare professional, with results of the exam.
CPT Code

CPT Category II

HCPCS

67028, 67030, 67031, 67036 6703867040, 67041-67043, 67101, 67105,
67107, 67108, 67110,67112, 67113,
67121, 67141, 67145, 67208, 67210,
67218, 67220, 67221, 67227, 67228,
92002, 92004, 92012, 92014, 92018,
92019, 92225, 92226, 92230, 92235,
92240, 92250, 92260, 99203-99205,
99213-99215, 99242-99245

2022F, 2024F,
2026F, 3072F

S0625, S3000,
S0620, S0621

ICD-9-CM
Procedure
14.1-14.5, 14.9,
95.02-95.04, 95.11,
95.12, 95.16

Denominator
1. The number of members who met the sample frame criteria
Numerators
1. The number of ALTCS EP/D members who had one or more Hb A1c tests during the
measurement period
2. The number of ALTCS EP/D members who had one or more fasting lipid profiles during
the measurement period
3. The number of ALTCS EP/D members who had a retinal exam during the measurement
period or a negative retinal exam in 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.
•
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.

iv

Data Sources
•
Recipient demographic information, as well as encounters and pharmacy data (Form C),
will be used by AHCCCS to identify the population.
•
Encounters will be used by AHCCCS to identify services. Contractors will use
administrative (claims) or laboratory data to collect additional service information. When
these data are not available, data will be collected from members’ medical records.
Data Collection Process
•
The population file will be obtained from the AHCCCS Decision Support system
(ADDS). The sample population will be selected by the Data Analysis & Research (DA&R)
unit of the Division of Health Care Management from this file.
•
Applicable services from administrative (encounter) data will paired with members
selected for the study.
•
After initial data collection by AHCCCS, electronic data files will be sent to Contractors.
These files will contain only the Contractors’ sample members.
•
Contractors will collect additional service 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, medical records,
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.
Data Validation
•
To verify that an HbA1c test, fasting lipid profile or retinal examination was performed,
Contractors must submit any one of the following for each member identified as receiving
indicator services: laboratory records, medical records, electronic data directly transmitted by
laboratories, or claims data
•
This documentation must contain confirmation of an examination being performed and the
date of service.
•
A double-blind validation may be performed by AHCCCS, matching the Contractorsupplied documentation 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.

v

Deviations from Previous Methodology
Codes to identify diabetic members were updated to the HEDIS® 2009 standard, including:
•
Added drugs to Table CDC-A, Prescriptions to Identify Members with Diabetes
•
Added CPT Category II codes 3044F and 3045F to Table CDC-D
•
Added CPT codes 67030, 67031, 67036, 67121, 67220 and 67221 to Table CDC-G
•
Deleted CPT codes 99499 from Table CDC-C
•
Added CPT codes 67041-67043 and 67113 to Table CDC-G
•
Clarified use of CPT Category II code 3072F in Table CDC-G
•
Deleted CPT codes 83715 and 83716 from Table CDC-H
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, by ALTCS
Contractor and by race/ethnicity.
•
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 national HEDIS means and percentiles for
Medicaid health plans as reported by the National Committee for Quality Assurance (NCQA),
and to the AHCCCS Minimum Performance Standard and Goal.
•
Individual Contractors will be compared to each other and to the statewide average.
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).

vi

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. Statistical
Significance Level: p <= .05

vii