MANAGED CARE UPDATE

Of Alphabet Soup and Diabetic Patients

by Randolph Brooks, O.D. 

Imagine my surprise when a patient who's also a managed-care executive told me he was having "TPA difficulties." I was about to launch into a lecture about why he should not treat himself when I realized what he was talking about: third-party administrator.

Today's health-care environment has a whole new language that sometimes looks more like alphabet soup than patient care. However, these acronyms have clear implications for what we do and the patient care we deliver. Here are some of the acronyms you should become familiar with.

• National Committee for Quality Assurance (NCQA). This private, non-profit organization assesses and reports on the quality of managed-care plans. On its web site (http://www.ncqa.org), NCQA says its mission is "to provide information that enables purchasers and consumers of managed health care to distinguish among plans based on quality, thereby allowing them to make more informed health-care purchasing decisions. This will encourage plans to compete based on quality and value, rather than on price and provider network alone."

• Health Plan Employer Data and Information Set (HEDIS 3.0). NCQA says it developed this set of standardized measures so consumers and benefits coordinators can compare health plans. Part of this goal is "to distinguish between accreditation, which looks at a health plan's structures and systems, and performance measurement, which looks at results the plan actually achieves."

Understand, HEDIS measures an entire health plan, not individual doctor performance. It can also establish benchmarks for particular measures.

• Quality Compass. Last fall, NCQA published its second annual report, "The State of Managed Care Quality, 1998." This report, also available on NCQA's web site, used health-care information collected from 447 managed-care organizations to develop a large database it calls Quality Compass 1998. This report "contains plan-specific performance, accreditation and member satisfaction information," according to NCQA.

Quality Compass 1998 contains more than 50 HEDIS measures from all 447 health plans that report to NCQA. This report discusses 10 specific clinical HEDIS measures, including diabetic eye exams.

NCQA's 1998 report presents data and recommendations in a variety of clinical and member-satisfaction areas. One significant finding: Only 39 percent of diabetics 31 and older got an eye exam in 1997, up just 1 percent from 1996.

The report advises plans to educate doctors so that patients have greater access to retinal exams. It concludes with the following statement: "To eliminate one potential obstacle to diabetic retinal exams, health plans should consider allowing diabetic patients to see their optometrist annually without a referral or co-pay."

• DQIP . The Diabetes Quality Improvement Project's purpose was to make uniform measures for diabetic care. The team consists of the NCQA, the Health Care Financing Administration, various physician groups and the American Diabetes Association.

One of the measures: Diabetics should have a dilated fundus examination every 1-2 years depending upon a set of clinical criteria. This differs slightly from a blanket recommendation of an annual exam.

What's significant, however, is the following statement: "The exam must be performed by an eye-care professional: ophthalmologist or optometrist. An alternative to a dilated eye exam is seven-field stereoscopic 30-degree fundus photography read by an optometrist or ophthalmologist."

The NCQA and DQIP reports clearly recognize optometrists as primary-care providers who can play a significant role in reducing diabetic eye disease. So, managed-care plans should start to look to our profession to help improve the care of these patients, an important measure of their own performance. Some HMOs have already started to allow diabetic patients direct access to optometrists and ophthalmologists without a referral or co-pay.

Although the NCQA itself does not credential practitioners, the organization develops the credentialing criteria health plans use to determine which doctors participate in their panels. Organized optometry has been working for the past several years to have credentialing criteria developed for optometry, and that process now appears to be moving along (see News Review, "Credentialing, Certification Movements Pick up Steam," page 4).

Meanwhile, we can also work to increase overall awareness of how important annual dilated fundus exams are for our diabetic patients. Three ways you can do this:

• Educate the plans. When you request an application to join an MCO's panel, indicate in your letter that you provide dilated fundus exams for diabetic patients. State that one of your goals as a participating provider is to help the plan improve its percentage of diabetic patients who received these annual retinal examinations.

• Educate primary care and other physicians. Report letters to PCPs can be an important tool for developing rapport and encouraging them to refer diabetic patients to you. Even if the patient comes to you without a referral from his or her PCP, send the doctor a report anyway.

Also visit PCPs or invite them to lunch. Let them know you'd like to help care for their diabetic patients and explain what you can do.

• Educate the patients. Flag or code every diabetic patient in your computer so it's easier for you to recall these patients. Once you've identified them, stress the importance of annual dilated fundus examinations in early detection and treatment of diabetic retinopathy. Also, implement an aggressive recall system to ensure these patients return when they need exams.

We have an ideal opportunity to participate in the care of diabetic patients. While this may help us increase our participation in managed care, our ultimate goal is to provide the best possible care for all our patients. This will help eliminate needless cases of blindness by offering the early detection that we as a profession can provide.

Send questions to Dr. Brooks c/o Review of Optometry, 201 King of Prussia Road, Radnor, PA 19089; or e-mail them to reviewofoptometry@jobson.com.