Pam Audish, RN, BSN, CCM, VP of Medical Management - Corporate

Pam Audish, RN, BSN, CCM

As Texas ACOs participate in value-based relationships with health plans that offer opportunities to demonstrate provision of cost-effective, high-quality diabetes care it is important to understand the diabetic population. To assess diabetes prevalence, Innovista analyzed Texas ACO commercial and Medicare 2019 claims data on the populations within our technology platform as of October 2019, which is not representative of the entire population currently managed. In participating Texas ACOs there are a total of 191,110 members. The overall prevalence of diabetes is 13%, or 24,517 patients, of which approximately 2/3 are adults age 18-64 and 1/3 are elderly ages 65 and older. Further slicing of Texas data shows that 9% of the commercial population and 33% of the Medicare population have diabetes. Using the John Hopkins ACG methodology the direct medical costs for care of patients with diabetes in our Texas ACOs is projected to be $420,767,000 or $17,049 per person in 2019. The American Diabetes Association stated that nationally people diagnosed with diabetes incur average medical expenditures of $16,752 per year in 2017, $300 less than then Texas diabetic projected costs in 2019.

Measuring quality of care for diabetes occurs through HEDIS measures, which although not perfect, are generally accepted measures of quality. Innovista compared the quality scores of 2017 to 2018 for primary care physicians participating in BCBS ACO. In 2017 Texas ACO primary care physicians scored 90.86% on HbA1c Testing. In 2018 Hba1c Testing results increased by 0.44% resulting in a score of 91.30%. Although the 2017 to 2018 50th percentile target decreased 0.65%, HbA1c Testing scores increased year over year. Additional diabetic measurements include HbA1c Control <8.0% and Diabetic Blood Pressure Control <140/90. Data can be gathered using “Level II CPT codes” or require submission of supplemental measure data and compliance audit to confirm results. The burden of supplemental data submission has made these measures difficult for physician participation in theses quality measures. However, these outcome measures remain the ultimate goal of improving the health of the diabetic patient.

As Texas ACOs look towards improving diabetes care, a comprehensive, action-oriented, collaborative approach between individuals, families, physicians, health plans, employers, and organizations such as Innovista, to work together to reduce the burden of this condition may include the following items.

  • Continuing to develop an evidence base of best practices for treating and managing diabetes.
  • Developing flowcharts that ensure patients receive preventive and diagnostic services.
  • Collaborating with care management teams to empower people with diabetes with knowledge, self-management support, and resources to proactively manage their disease and prevent or control diabetes complications.
  • Increasing the use of dieticians, community health workers, and pharmacists.
  • Continuing to incorporate information management systems, such as patient registries, to identify patients, track health status and delivery of services and provide information about the patient’s status to the entire care team.
  • Increasing friendliness of data submission processes for quality measure collection.
  • Exploring the use within your provider groups of utilizing Level II CPT codes more consistently.
  • Developing strategies to implement telehealth and other emerging resources.
  • Increasing access to and health benefit coverage of lifestyle change programs.
  • Exploring partnerships within the community to help implement evidence-based practices and strategies.

Quality, cost-effectiveness and patient-centricity are likely to remain the primary goals of the health care system. As Texas looks to increase programs addressing diabetes care, the collaborative work of all stakeholders will assist with the successful transition to a more patient-centered, value-based system approach demonstrating the ability to effectively manage diabetes to prevent or delay the development of serious complications.