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

PERFORMANCE MEASURES FOR DIABETES CARE
Measurement Period: Oct. 1, 2009, through Sept. 30, 2010

November 2011

“Our first care is your health care.”

Thomas J. Betlach
Director, AHCCCS

Prepared by the Division of Health Care Management

Arizona Long Term Care System (ALTCS)
PERFORMANCE MEASURES FOR DIABETES CARE
For the Measurement Period Oct. 1, 2009, through Sept. 30, 2010
INTRODUCTION

1

ABOUT DIABETES

2

THE CASE FOR IMPROVEMENT

2

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

4
4
4
4
4
5
4
5
5

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

6
6
6
6

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

6
7
7

REFERENCES

7

TABLES AND FIGURES

9

APPENDIX: METHODOLOGY AND TECHNICAL SPECIFICATIONS

15

ii

Arizona Health Care Cost Containment System (AHCCCS)
Arizona Long Term Care System (ALTCS)
PERFORMANCE MEASURES FOR DIABETES CARE
For the Measurement Period Oct. 1, 2009, through Sept. 30, 2010

INTRODUCTION
potentially
deadly
disease.
Surveys
conducted in recent years have found that
about 60 percent of American adults are
either overweight or obese.6,7 The proportion
of Arizonans who are overweight or obese is
about equal to the national rate.8 Another
study found that nearly half of obese persons
have type 2 diabetes.9

Diabetes is a serious health problem that is
growing rapidly in the United States.
Approximately 19.6 million American
adults, or 8.7 percent of all people 18 years
and older, have been diagnosed with
diabetes, according to an estimate by the
federal Centers for Disease Control and
Prevention (CDC).1 About 1.9 million new
cases of diabetes were diagnosed among
U.S. adults in 2010.1

Hispanics, Blacks, American Indians and
Alaska Natives are approximately twice as
likely to have diabetes as non-Hispanic
Whites in the U.S. The prevalence of
diabetes also is higher among older
Americans – 26.9 percent of all people 65
and older have diabetes – as well as among
people with low socioeconomic status and
those covered by Medicaid.1,4,5

The number of people diagnosed with
diabetes in the U.S. has more than tripled in
the last 29 years.4 The prevalence of
diabetes in Arizona also increased during
that time.5 The rate of diagnosed diabetes in
Arizona is about equal to the U.S. rate
overall.3

The percentage of adults diagnosed with
diabetes in Arizona, by age, 1994 – 2009
follows this prevalence of diabetes in people
65 and older.2

Prevalence of Diabetes, Arizona vs. U.S.:
Adults who have ever been told by a doctor that they
have diabetes, 2004 - 2009
10%
9%
8%
7%
6%
5%
4%
3%
2%
1%
0%
2004

2005

Arizona

2006

2007

2008

2009

U.S.

Source: Centers for Disease Control and Prevention

A sedentary lifestyle and dramatic rise in
obesity in the U.S. population are
contributing to the increase in this costly and

Source: Centers for Disease Control and Prevention

1

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
At
least
4
million
productivity.9
hospitalizations annually in the U.S. are
associated with diabetes.10, 12

In Arizona, diabetes-related discharges from
non-federal hospitals numbered 102,827 in
2006, accounting for more than $3.5 billion
in total charges, with an average length of
stay of 5.1 days.11
It has been estimated that by 2034, the
population with type 2 diabetes will have
doubled, with annual medical spending
related to diabetes growing to $336 billion.

ABOUT DIABETES
•

People with diabetes are more susceptible to acute illness and have worse health
outcomes than non-diabetics. For example, people with diabetes are more likely to die
from pneumonia or influenza.

•

Two of three 3 people with diabetes die of heart disease or stroke.

•

Diabetes is the #1 cause of adult blindness.

THE CASE FOR IMPROVEMENT
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 so they can manage their lifestyles and help control their disease.1,15
Glucose Control –– Control of hyperglycemia (increased blood sugar) is critical to reducing
complications associated with diabetes. Physicians utilize a glycosylated hemoglobin, or HbA1c,
test to monitor 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.
•

Patients with diabetes who maintain near normal HbA1c levels can gain, on average, an
extra five years of life, eight years of sight and six years free from kidney disease.

•

HbA1c control can result in quality-of-life improvements such as increased work
productivity and lower health care use, while preventing the development of eye, kidney
and nerve disease.

2

Lipid Management –– Control of cholesterol and lipids can reduce cardiovascular complications
by 20 to 50 percent.4 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 exams and timely treatment, including laser therapy,
could reduce the development of severe vision loss by up to 60 percent.4 People with diabetes
should have comprehensive dilated eye examinations by ophthalmologists or optometrists, in
order to detect and treat retinopathy and prevent vision loss.
•

New analyses from the Action to Control Cardiovascular Risk in Diabetes (ACCORD)
trial released in July 2010 show that more intensive control of lipids and HbA1c together
significantly slowed the progression of diabetic retinopathy over four years.19

The purpose of this study is to monitor performance of managed care organizations contracted
with the Arizona Health Care Cost Containment System (AHCCCS) to provide services to
Arizona Long Term Care System (ALTCS) 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 of the disease.
Results of the measurement are used to determine whether these managed care organizations
(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.

STUDY METHODS
AHCCCS modeled its HEDIS-like performance measure after the Healthcare Effectiveness Data
and Information Set (HEDIS) 2011 specifications for this measurement. Developed by the
National Committee for Quality Assurance (NCQA), HEDIS is a widely adopted methodology
that allows for comparisons with national benchmarks, including the mean (average) for
managed care plans serving Medicaid and commercial members.
AHCCCS utilized three indicators to measure Contractor performance: HbA1c testing, lipid
screening, and retinal exams.
Population
This study included elderly and physically disabled (E/PD) members enrolled with ALTCS
managed care organizations who had a diagnosis 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).
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
3

also may be identified as having diabetes when insulin or other certain types of drugs used to
treat diabetes is dispensed to the member from a pharmacy.
Measurement Period
The measurement period for this study was the AHCCCS contract year from October 1, 2009
through September 30, 2010.
Sample Frame
The sample frame consisted of E/PD members who were:
•
ages 18 through 75 years as of September 30, 2010,
•
continuously enrolled with one ALTCS Contractor for at least 11 member months
during the measurement period, and
•
enrolled with that Contractor on the last day of the measurement period.
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 are loaded into the AHCCCS Decision Support
System (ADDS), from which a sample of members was selected and initial service data were
collected.
However, as many as 80 percent of ALTCS elderly and physically disabled members are also
covered by Medicare, which is the primary payer of services for these members. Medicare
providers may bill AHCCCS Contractors for copayments for their members, but when they do
not, AHCCCS does not have complete data on services provided to “dually enrolled” members.
Thus, additional data for these measures is collected by Contractors using a hybrid methodology
process.
AHCCCS provided an electronic data collection tool along with detailed instructions to each
Contractor, which was used to collect additional service data from medical records and
Contractor claims systems. The additional information was entered by Contractor staff into the
electronic tool.
Data Quality and Reliability
AHCCCS conducts annual studies to evaluate the completeness of ALTCS encounter data
compared with the corresponding medical records. The most recent study of claims paid by
ALTCS Contractors shows an overall error rate of 2.4 percent for outpatient encounters.
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. A sample of documentation was reviewed by
AHCCCS and Contractor data were corrected as necessary.

4

Study Indicators
•
HbA1c testing — This indicator measured the percent of members who had one or
more HbA1c tests during the measurement year.
•
Lipid (LDL-C) profile —This indicator measured the percent of members who had
one or more fasting lipid profiles during the measurement year.
•
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) in the year prior to the measurement year also may be counted.
Performance Standards
AHCCCS has established a Minimum Performance Standard (MPS) for each diabetes measure,
which is specified in the CYE 2010 ALTCS E/PD contract.
AHCCCS Performance Standards
Measure

MPS

Goal

HbA1c testing

80%

89%

Lipid screening

72%

91%

Retinal exams

60%

68%

If a Contractor does not meet the minimum standard, it must implement a Corrective Action Plan
and may face a financial sanction if it fails to show improvement. AHCCCS also has set goals
that Contractors should strive to meet if they are already meeting minimum standards.
National Benchmarks
The most recent HEDIS national means reported by NCQA are for the measurement period of
calendar year 2010 (January 1, 2010 through December 31, 2010).
HEDIS National Means
Measure

Medicaid

Commercial

Hb A1c testing

82.0%

89.9%

Lipid screening

74.7%

85.6%

Retinal exams

53.1%

57.7%

5

RESULTS
The measurement included 1,412 sample members enrolled with eight long-term care
Contractors during the measurement period. Results were calculated overall and by Contractor.
Data were also analyzed to determine if there were significant differences by members’ race or
ethnicity.
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 defined as p< .05; that is, the probability of obtaining such a difference by
chance only is relatively low.
HbA1c Testing
The overall rate of HbA1c testing during the measurement year was 77.8 percent, compared with
the previous rate of 86.5 percent (Table 1). The decrease is statistically significant (p<.001).
Rates by Contractor ranged from 49.2 percent to 92.5 percent. However, it should be noted that,
among the four Contractors continuing as AHCCCS ALTCS Contractors in contract year ending
(CYE) 2012 (continuing Contractors), the overall performance rate was 87.1 percent. This rate
is an increase from the previous year and is above both the AHCCCS Minimum Performance
Standard (MPS) (Figure 1) and HEDIS national Medicaid Mean.
Individually, six Contractors, including all four continuing Contractors, exceeded the AHCCCS
MPS. Four Contractors, including three of the four continuing Contractors, exceeded the HEDIS
national Medicaid mean. Two Contractors also exceeded the AHCCCS goal and the HEDIS
national commercial mean.
Lipid (LDL-C)
The overall rate of members who had an LDL-C test or fasting lipid profile during the
measurement year was 71.5 percent (Table 2), compared with 77.9 percent in the previous
measurement. The decrease is statistically significant (p< .001). Contractor rates ranged from
41.1 percent to 91.0 percent. However, it should be noted that, among the four continuing
Contractors, the overall performance rate was 80.7 percent. This rate is an increase from the
previous year and is above both the AHCCCS MPS and HEDIS national Medicaid Mean.
Individually, five Contractors, including all four continuing Contractors, exceeded the MPS
(Figure 2). Four of the same five Contractors also exceeded the HEDIS national Medicaid mean
and two surpassed the HEDIS national commercial mean.
Eye Examinations
The overall rate of members who had a dilated retinal exam in the measurement year or a
negative exam in the previous year was 67.7 percent, compared with 63.9 percent in the previous
measurement (Table 3). The increase is statistically significant (p= .028). Rates by Contractor
ranged from 47.6 percent to 83.5 percent. The four continuing Contractors had an overall
performance rate of 71.6 percent for the measurement period. This rate is a relative 15.1%
increase from the previous year and is well above both the AHCCCS Goal and HEDIS national
Medicaid and Commercial Plan Means.

6

Individually, six Contractors, including the four continuing Contractors, exceeded the MPS
(Figure 3). Seven, including the four continuing Contractors, surpassed the HEDIS national
means for Medicaid health plans. Six Contractors surpassed the HEDIS national commercial
mean. Four, including two of the four continuing Contractors, had rates that exceeded the
AHCCCS goal. The AHCCCS overall rate exceeded the HEDIS national Medicaid mean by 14.6
percent; it also exceeded the commercial mean by 10.0 percent.
Results by Race/Ethnicity
Differences by race/ethnicity are noted in the table below. Results for Native Americans should
be interpreted with caution as there were only 21 members in that group.
Rates by Race/Ethnicity, CYE 2010
Hb A1c

Lipid

Retinal

76.96%

70.14%

66.15%

Hispanic

74.6%

67.4%

69.2%

Black

83.2%

85.3%

72.6%

Native American

91.3%

69.6%

65.2%

Other/Unknown

82.6%

78.1%

68.9%

White

1

1 Non-Hispanic Whites were used as the reference group for analyzing
whether there were disparities in use of services based on race/ethnicity.

DISCUSSION
Overall Results
This is the fifth consecutive year that the AHCCCS overall rate for eye exams exceeds the
national average for commercial health plans. The AHCCCS overall rates for HbA1c and
LDL-C testing had a statistically significant decrease. This decrease was due to nonsubmission of documentation of services by two of the four Contractors not awarded CYE
2012 contracts.
Contractor Performance
All four of the Contractors awarded CYE 2012 contracts (Bridgeway Health Solutions,
Evercare Select, Mercy Care Long Term Care Plan and SCAN Long Term Care), met the
AHCCCS Minimum Performance Standards for all measures. Mercy Care Plan continues to
show strong performance in these measures, meeting all minimum performance standards for
the past five years.
Most Contractors had corrective action plans (CAPs) in place for at least one of the diabetes
measures prior to this measurement. As most of these CAPs were implemented by early
2009, it appears corrective actions and regulatory pressure from AHCCCS resulted in the
improvements demonstrated in the current measurement. An example is Evercare Select’s
statistically significant increase in the rate for eye examinations.

7

Cochise Health Systems and Pima Health systems, which were not awarded contracts for
CYE 2012, reported lower rates for all three measures from the previous measurement.
Quality Improvement Efforts
AHCCCS Contractors have utilized a variety of strategies to improve care of members
diagnosed with diabetes. 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 Primary Care Physicians (PCPs) of
members with diabetes who are due or overdue for specific services.
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.
Contractors also must ensure that, once improvement is achieved, they continue to focus on
sustaining performance.

8

REFERENCES
1

Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national
estimates on diabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services,
Centers
for
Disease
Control
and
Prevention,
2011.
Available
at:
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf . Accessed July 7, 2011.
2
Centers for Disease Control and Prevention. Diabetes and Trends
http://apps.nccd.cdc.gov/DDTSTRS/Index.aspx?stateId=4&state=Arizona&cat=prevalence&Data=data&view=
TOPA&trend=prevalence&id=1 Accessed July 7, 2011
3
Centers for Disease Control and Prevention. Behavioral Risk Factor surveillance system, Prevalence and
Trends: diabetes. http://apps.nccd.cdc.gov/brfss/list.asp?cat=DB&yr=2009&qkey=1363&state=All. Accessed
Oct. 19, 2010.
4
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/chronicdisease/resources/publications/AAG/ddt.htm. Accessed Sept. 22, 2008.
5
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/table15.htm. Accessed Sept. 15, 2008.
6
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.
7
Vega CP. Stress and obesity: Partners in disease. Medscape 2007. Available at:
http://www.medscape.com/viewprogram/7780. Accessed Sept. 25, 2009.
8
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%20PRINTED%20REPORT%20WITH%20COVER.pdf. Accessed
July 7, 2008.
9
Devastating toll of diabetes reaches $174 billion [press release]. Alexandria, VA: American Diabetes
Association; Jan. 23, 2008. Available at: http://www.diabetes.org/for-media/pr-devastating-toll-of-diabetesreaches-174-billion-012308.jsp . Accessed Feb. 7, 2008.
10
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/rr5311a1.htm. Accessed Sept. 22,
2009.
11
Arizona Diabetes Coalition, Surveillance Committee. Arizona Diabetes Indicators Annual Report 2008.
Arizona Department of Health Services, Diabetes Prevention and Control Program. July 2008. Available at
http://www.azdiabetes.gov/pdf/IndicatorsReportJuly2008.pdf. Accessed Oct. 19, 2010.
12
L Brookes. Diabetes Control and Prevention Are the New Focus of Health Plans. Medscape Diabetes &
Endocrinology.
Aug.
3,
2010.
Available
at:
http://www.medscape.com/viewarticle/725946?src=mp&spon=17&uac=81844DT
Accessed Aug. 16, 2010.
13
Barclay L. Tight Control of Hyperglycemia and Dyslipidemia May Slow Progression of Diabetic Retinopathy
MedscapeCME Clinical Briefs. July 8, 2010. Available at http://cme.medscape.com/viewarticle/724693

For questions or comments about this report please contact:
Kim M. Elliott, Ph.D., C.P.H.Q.
Administrator
Clinical Quality Management
DHCM, AHCCCS
Kim.Elliott@azahcccs.gov

9

TABLE 1
AHCCCS Clinical Quality Performance Measures for Diabetes
Hb A1c TESTS - ALTCS E/PD MEMBERS WITH DIABETES
Current Measurement Period: Oct. 1, 2009, through Sept. 30, 2010
Minimum Performance Standard: 80%

Contractor

Included
Cases

Total
Receiving
Hb A1c
Test

Percent
Receiving
Hb A1c
Test

Relative
Percent
Change

Significance
Level

194

168

86.6%

3.9%

p=.389

162

135

83.3%

233

203

87.1%

3.2%

p=.416

212

179

84.4%

266

246

92.5%

2.7%

p=.305

301

271

90.0%

199

160

80.4%

-6.1%

p=.200

153

131

85.6%

892

777

87.1%

0.7%

p=.698

828

716

86.5%

124

61

49.2%

-34.0%

p<.001

102

76

74.5%

252

128

50.8%

-45.1%

p<.001

238

220

92.4%

140

127

90.7%

-0.4%

p=.912

157

143

91.1%

92

74

80.4%

6.0%

p=.459

87

66

75.9%

608

390

64.1%

-29.9%

p<.001

584

505

86.5%

1,500

1,167

77.8%

-10.0%

p<.001

Continuing Contractors
Bridgeway Health Solutions *

Evercare Select *

Mercy Care LTC *

SCAN Long Term Care *
Continuing Contractor Total:

Discontinued Contractors
Cochise Health Systems
Pima Health System
Pinal/Gila County LTC *
Yavapai County LTC*
Discontinued Contractor Total:

Cumulative Total
TOTAL

1,412
1,221
86.5%
Notes: Bridgeway Health Solutions, Evercare Select, Mercy Care LTC and Scan Long Term Care were awarded
continuing contracts in May 2011 for CYE 2012.
* 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 (p< .05).
Results of the previous measurement period (Oct. 1, 2008, through Sept. 30, 2009), are shown in shaded rows

10

Figure 1
Hb A1c TESTS - ALTCS E/PD MEMBERS WITH DIABETES
Current Measurement Period: Oct. 1, 2009, through Sept. 30, 2010
100%
Minimum Performance Standard

80%

60%

40%

20%

0%
Bridgeway
Health
Solutions *

Cochise
Health
Systems

Evercare
Select *

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

Current Measurement

TOTAL

Previous Measurement

Notes:
Bridgeway Health Solutions, Evercare Select, Mercy Care LTC and Scan Long Term Care were awarded continuing
contracts in May 2011 for CYE 2012.
* Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard (MPS).

11

TABLE 2
AHCCCS Clinical Quality Performance Measures for Diabetes
ANNUAL LIPID PROFILES - ALTCS E/PD MEMBERS WITH DIABETES
Current Measurement Period: Oct. 1, 2009, through Sept. 30, 2010
Minimum Performance Standard: 72%

Contractor

Included
Cases

Total
Receiving
Fasting
Lipid

Percent
Receiving
Fasting
Lipid

Relative
Percent
Change

Significance
Level

194

146

75.3%

1.6%

p=.798

162

120

74.1%

233

191

82.0%

6.6%

p=.184

212

163

76.9%

266

242

91.0%

3.3%

p=.256

301

265

88.0%

199

147

73.9%

-1.7%

p=.783

153

115

75.2%

892

726

81.4%

1.6%

p=.489

828

663

80.1%

124

51

41.1%

-37.4%

p<.001

102

67

65.7%

252

109

43.3%

-38.0%

p<.001

238

166

69.7%

140

121

86.4%

-4.4%

p=.278

157

142

90.4%

92

66

71.7%

0.7%

p=.944

87

62

71.3%

608

347

57.1%

-23.7%

p<.001

584

437

74.8%

1,500

1,073

71.5%

-8.2%

p<.001

Continuing Contractors
Bridgeway Health Solutions *

Evercare Select *

Mercy Care LTC *

SCAN Long Term Care*
Continuing Contractor Total:

Discontinued Contractors
Cochise Health Systems
Pima Health System LTC
Pinal/Gila County LTC *
Yavapai County LTC
Discontinued Contractor Total:

Cumulative Total
TOTAL

1,412
1,100
77.9%
Notes: Bridgeway Health Solutions, Evercare Select, Mercy Care LTC and Scan Long Term Care were awarded
continuing contracts in May 2011 for CYE 2012.
* 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 (p< .05).
Results of the previous measurement period (Oct. 1, 2008, through Sept. 30, 2009), are shown in shaded rows

12

Figure 2
LIPID PROFILES - ALTCS E/PD MEMBERS WITH DIABETES
Current Measurement Period: Oct. 1, 2009, through Sept. 30, 2010
100%

80%

60%

40%

20%

0%
Bridgeway
Health
Solutions *

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

TOTAL

Previous Measurement

Notes:
Bridgeway Health Solutions, Evercare Select, Mercy Care LTC and Scan Long Term Care were awarded continuing
contracts in May 2011 for CYE 2012.
* Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard (MPS).

13

TABLE 3
AHCCCS Clinical Quality Performance Measures for Diabetes
RETINAL EXAMS - ALTCS E/PD MEMBERS WITH DIABETES
Current Measurement Period: Oct. 1, 2009, through Sept. 30, 2010
Minimum Performance Standard: 60%

Contractor

Included
Cases

Total
Receiving
Retinal
Exam

Percent
Receiving
Retinal
Exam

Relative
Percent
Change

Significance
Level

194

122

62.9%

5.0%

p=.561

162

97

59.9%

233

161

69.1%

20.1%

p=.011

212

122

57.5%

266

222

83.5%

10.7%

p=.019

301

227

75.4%

199

134

67.3%

153

69

45.1%

892

639

71.6%

828

515

62.2%

124

59

47.6%

102

59

57.8%

252

144

57.1%

238

146

61.3%

140

108

77.1%

157

123

78.3%

92

66

71.7%

87

59

67.8%

608

377

62.0%

584

387

66.3%

1,500

1,016

67.7%

Continuing Contractors
Bridgeway Health Solutions*
Evercare Select*
Mercy Care LTC*
SCAN Long Term Care*
Continuing Contractor Total:

49.3%

p<.001

15.1%

p<.001

-17.7%

p=.124

-6.8%

p=.344

-1.5%

p=.804

5.8%

p=.568

-6.5%

p=.125

6.0%

p=.028

Discontinued Contractors
Cochise Health Systems
Pima Health System LTC
Pinal/Gila County LTC*
Yavapai County LTC *

Discontinued Contractor Total:

Cumulative Total
TOTAL

1,412
902
63.9%
Notes: Bridgeway Health Solutions, Evercare Select, Mercy Care LTC and Scan Long Term Care were awarded
continuing contracts in May 2011 for CYE 2012.
* 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 (p< .05).
Results of the previous measurement period (Oct. 1, 2008, through Sept. 30, 2009), are shown in shaded rows

14

Figure 3
RETINAL EXAMS - ALTCS E/PD MEMBERS WITH DIABETES
Current Measurement Period: Oct. 1, 2009, through Sept. 30, 2010
100.0%

80.0%

Minimum Performance Standard
60.0%

40.0%

20.0%

0.0%
Bridgeway
Health
Solutions*

Cochise
Health
Systems

Evercare
Select*

Pima Health
System LTC

Pinal/Gila
County LTC*

Current Measurement

Mercy Care
LTC*

SCAN Long
Term Care*

Yavapai
County LTC *

TOTAL

Previous Measurement

Notes:
Bridgeway Health Solutions, Evercare Select, Mercy Care LTC and Scan Long Term Care were awarded continuing
contracts in May 2011 for CYE 2012.
* Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard (MPS).

15

Appendix:
METHODOLOGY
Arizona Health Care Cost Containment System (AHCCCS)
Arizona Long Term Care System (ALTCS)
DIABETES PERFORMANCE MEASURES
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, 2009, through September 30, 2010
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, using a HEDIS® 2011 like
definition. Members may be identified as having diabetes 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 measurement period
•
Members with a gap in coverage resulting in less than 11 member-months of
enrollment with the same health plan during the measurement period
•
Members with steroid-induced diabetes or gestational diabetes
•
Members with a diagnosis of polycystic ovaries who did not have two face-to-face
encounters with a diagnosis of diabetes in any setting during the measurement year or
prior year

16

•

Tribal and Fee for Service members, due to the inability to accurately collect
complete data on these populations. These members may obtain 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 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, 2010,
who were continuously enrolled with one ALTCS E/PD Contractor for at least 11 membersmonths during the measurement period, and diagnosed with type 1 or type 2 diabetes.
•
Prior Period Coverage (PPC) is considered a break in enrollment.
•
A change of county service area with the same Contractor is not considered a break in
enrollment.
•
Members must have been enrolled on the last day of the measurement period.
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. Each
Contractor’s lowest rate of the three indicators as reported for the previous measurement will be
used to calculate the estimated proportion of incidence for the current sample. An over sampling
rate of 10 percent also will be utilized to determine the sample.
Identification of Members with Diabetes
Members with diabetes will be identified, according to HEDIS 2011 like 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.
Indicators

AHCCCS will work with ALTCS E/PD Contractors to collect data for this measurement
through a hybrid methodology, following a HEDIS like process.
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 2011 like 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

17

CPT Code
83036, 83037

Codes to Identify HbA1c Tests
CPT Category II
3044F, 3045F, 3046F

or
•

At a minimum, documentation in the medical record must include a note indicating
the date on which the HbA1c test was performed and the result. The organization may
count notation of the following in the medical record review:
o A1c
o Hemoglobin A1c
o HgbA1c
o HbA1c
o Glycohemoglobin A1c

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 2011 like 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
CPT Category II
80061, 83700, 83701, 83704, 83721
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.
18

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 eye-care professional, with results of the exam.

•

a claim or encounter, using codes listed in the following table:

or

CPT Category
HCPCS
II
67028, 67030, 67031, 67036 2022F, 2024F, S0625,
67039-67040, 67041-67043, 2026F, 3072F
S3000,
67101, 67105, 67107, 67108,
S0620,
67110,67112, 67113, 67121,
S0621
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
CPT Code

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 HbA1c 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.

19