Does Diabetes Disease Management Save Money and Improve Outcomes?

Jaan Sidorov, MD, FACP, CMCE, Robert Shull, PHD, Janet Tomcavage, RN, MSN, CDE, Sabrina Girolami, RN, BSN, Ronald Harris, MD, FACE, Nadine Lawton, RN

Disclosures

Diabetes Care. 2002;25(4) 

In This Article

Research Design and Methods

Geisinger Health Plan (GHP) is a federally qualified, not-for-profit group model HMO with 295,000 enrollees in 41 counties in northeastern and central Pennsylvania. It is part of the Geisinger System, which also supports a multispecialty group practice clinic consisting of 587 physicians located in 64 clinic sites as well as two closed-staff hospitals. GHP also independently contracts with a network of 4,192 providers and 57 hospitals. Several types of managed care insurance are offered by GHP, including commercial, Medicare risk, small business, group, individual, and third-party administration (TPA). Seventy-three percent of enrollees use one of a series of pharmacy benefit packages that can be purchased as a separate rider with a variety of patient co-pay options. Glucose monitors and strips are considered durable medical equipment and are covered unless specifically excluded, as negotiated under a TPA arrangement. GHP is fully accredited by the National Committee on Quality Assurance. As part of the accreditation process, GHP conducts yearly measures of the quality of diabetes care using HEDIS criteria, which is a set of performance measures obtained using a proscribed methodology designed to enable purchasers to reliably compare the performance of different managed health care plans [25].

Overview
On 1 April 1997, GHP’s disease management department began to recruit patients for diabetes disease management. At the time of this study, our department used a network of 51 primary care nurse educators and case managers. These registered nurses provide patient education and case management services in all physician clinics that contract with GHP for primary care services. Depending on member enrollment and geographic proximity, each nurse is responsible for 1–15 primary care sites. Each nurse is trained in diabetes patient education as well as tobacco cessation, congestive heart failure, hypertension, chronic obstructive pulmonary disease, and asthma. In fiscal year 2000, the total cost of this program, including capital, totaled just over $4.2 million, with 4,262 continuously and currently enrolled patients who entered diabetes disease management. This consists of ~43% of all patients ever seen by the disease management nurses [26].

Patient education by the nurses at each primary care clinic is provided one on one or in group settings by appointment. Each nurse encounter is documented in the patient’s medical record for physician review and co-signature. Nurses are allowed to use judgment in accommodating local physician preferences and practice styles. There is no charge rendered for the nurse education and no net financial gain or loss for the primary care site. Each nurse is also responsible for baseline and ongoing collection of data from the patient or from the medical record for later entry in database registries. Use of this approach to achieve outcomes in the areas of tobacco cessation, living wills, and diabetes care has been previously reported [27–29].

Description of diabetes disease management
A detailed description of the GHP diabetes disease management program has been described elsewhere [29]. Briefly, this is a package of interventions, given over 1 year, consisting of promotion of diabetes clinical guidelines by the nurses in their day-to-day interactions with primary care physicians and patients, HMO-sponsored continuing medical education sessions for primary care providers, early and appropriate specialty clinic referral, and primary care site-based patient education and case management by the HMO nurses. Patients must voluntarily opt in to participate. To aid recruitment, nurses can arrange the one-time provision of a glucose meter and 100 glucose meter strips at no cost, using clinical criteria from the diabetes guidelines. Additional glucose meter strips are available for monthly co-payment, ranging from $8 to $15. Any patient with diabetes may self- refer or be referred by their physician. Depending on patient and physician preference, baseline HbA1c measurement, and the presence of any diabetic complications, all patients are seen one to four times by the nurse from the date of referral. All participants are educated about the appropriate use of a glucose meter, the role of diet and exercise, the importance of HbA1c testing, medication management, the management of hypoglycemia, and teaming closely with physicians in the use of staged diabetes management clinical guidelines [30] to achieve optimum blood glucose control.

Analysis of savings in diabetes disease management
GHP enrollees eligible for HEDIS analyses at the time of this study totaled 172,015 commercial HMO, 36,456 Medicare risk, and 47,004 patients with "point-of-service" insurance. Of 255,475 HMO enrollees, 6,799 (2.7%) fulfilled HEDIS criteria for the presence of diabetes. Of this latter group, 3,118 (45.8%) had been seen at least once by a GHP nurse since the program began in April 1997. HEDIS-specific data on all patients were obtained by a separate group of nurses (in the case of chart reviews) or data analysts (in the case of claims extracts) devoted to measuring quality improvement outside of the disease management program. Personnel responsible for collecting or reporting HEDIS data were unaware of those patients that were in disease management at the time of their review.

All GHP members with commercial, including point-of-service, or Medicare risk insurance fulfilling HEDIS criteria for diabetes during the 2-year period from 1 July 1999 to 30 June 2001 had all enrollment data and submitted claims for health or medical care downloaded from the HMO claims database and entered into SAS version 8.0. The criteria used to identify members who fulfill HEDIS criteria are described elsewhere [25]. Pharmacy claims were not included in this analysis. Unique member identification numbers were sorted into those who had seen an HMO disease management nurse at least once for diabetes education (program patients) and those not entered into disease management (nonprogram patients). Mean total claims paid per member per month, mean admissions per patient per year, mean number of inpatient days per patient per year, and mean number of emergency room and primary care office visits were compared in the two groups. We also compared HEDIS scores for HbA1c testing, percent not in control, diabetic eye screening, and kidney disease screening in the two groups. Duration or specific type of diabetes is not included in any HEDIS measure, and this information is not included in this analysis. 2 tests were used to examine the significance of any observed differences in tests of proportion. Student’s t tests were used to examine the statistical significance of any observed differences in tests of continuous data. Multiple linear regression and the resulting F statistic was used to control for age, sex, presence of pharmacy benefit, HMO enrollment duration, and insurance type to more precisely describe the significance of continuous data.

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