The percentage of Medicaid, commercial, and Medicare members with diabetes (Type 1 and Type 2) ages 18-75, who were continuously enrolled during the reporting year, who had each of the following:
- Hemoglobin A1c tested (once during reporting year)
- Poor hemoglobin A1c controlled (most recent HbA1C > 9.5 percent)
- Eye exam performed (once during reporting year, or year prior for low-risk patients)
- Lipid profile (once during reporting year or year prior)
- Lipid control (most recent LDL value < 130 mg/DL)
- Monitoring for diabetic nephropathy
- Blood pressure controlled (most recent values below 140 systolic and 90 diastolic)
- Foot exam performed (once during reporting year)
Health plans will report eight separate rates (one for each aspect of diabetes care identified) for each payer (i.e., Medicaid, commercial, and Medicare). An Administrative Data Specification is not included for the diabetes data set because data systems are unlikely to contain all necessary aspects of diabetes care measured.
Two numerators, blood pressure controlled and foot exam performed, must be obtained from the medical record. Use of the hybrid method to calculate each rate is highly recommended, particularly for plans reporting this measure set for the first time.
Hybrid Method Specification Calculation
This specification uses claims/encounter or pharmacy data to identify members with diabetes and claims/encounter data, automated laboratory data or medical record review to determine if the service was performed or threshold achieved. Eight separate calculations are required for each of the plan’s populations (Medicaid, commercial, and Medicare).
Denominator
| Populations: | Medicaid, commercial, Medicare (report each population separately). |
| Age(s): | 18-75 years as of December 31 of the reporting year. |
| Continuous Enrollment: |
Reporting year. Members may have no more than one gap in enrollment of up to 45 days during the reporting year. To determine continuous enrollment for a Medicaid beneficiary for whom enrollment is verified monthly, the member may not have more than one gap in coverage [i.e., a member whose coverage lapses for two months (60 days) is not considered continuously enrolled]. A member must have been enrolled on December 31 of the reporting year. |
| Requirement: | Members must be diabetic; exclude any women with gestational diabetes. To identify diabetics search for: Those who were prescribed or dispensed insulin and/or oral hypoglycemics/ antihyperglycemics during the reporting year on an ambulatory basis. (See the General Notes on page 15 for a list of medications.)
OR Those who had two face-to-face encounters with different dates of service in an ambulatory setting or non-acute inpatient setting or one face-to-face encounter in an acute inpatient or emergency room setting during the reporting year with a diagnosis of diabetes. See the Appendix for diabetes diagnosis codes and procedure codes to identify ambulatory, acute inpatient, non-acute inpatient, and ER encounters, as well as codes to exclude women with gestational diabetes. |
Note: Many plans find a high rate of false positives when they use laboratory data to identify diabetics, because diabetes diagnosis codes frequently are reported on laboratory tests used to rule out diabetes. Therefore, laboratory data should not be used to identify diabetics.
For plans which will be using medical records, there is an electronic data abstraction tool available from the Texas Medical Foundation. Call 1-888-691-9167 (toll free) for more information.