April 1, 2015
You have an opportunity to expand your medical eyecare services, and educate patients about the eye health monitoring and treatment you provide. More than 30 percent of Americans diagnosed with diabetes have some form of diabetic retinopathy, according to the National Eye Institute, a part of the National Institutes of Health. This translates to an estimated 7.6 million Americans with the condition.
You must know what a HEDIS score is and how you contribute to its calculation.
“The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of America’s health plans to measure performance on important dimensions of care and service.” HEDIS is designed to compare health plan performance against each other and against national benchmarks.
CMS requires HMOs submit HEDIS data for Medicare Advantage enrollees. HEDIS data will be a requirement for the ACA narrowed networks. If you are not contributing positively toward improved HEDIS scores for diabetics, you greatly reduce your chance of being part of the narrowed networks of the ACA.
HEDIS consists of 81 measures across five domains of care. The five domains of care are:
• Effectiveness of Care
• Access/Availability of Care
• Experience of Care
• Utilization and Relative Resource Use
• Health Plan Descriptive Information
Comprehensive Diabetes Care is one of the targeted areas for HEDIS scores. Since the eyecare professional (ECP) is often the first touch with the medical community a patient may have, it is important you perform your role as part of the health care team managing patient care.
As an important part of the medical team managing diabetic patients, here are seven facts about diabetes that you should know and be able to use in a conversation with any medical director or health plan administrator.
1) 29.1 million people, or 9.3 percent of the US population, have diabetes.
2) 8.1 million people, or 27.8 percent of the population with diabetes, are undiagnosed.
3) 7.6 million people, or 30 percent of the US population of Americans diagnosed with diabetes, have some form of diabetic retinopathy [NEI].
4) Hispanic and African-Americans are at greater risk for developing diabetic retinopathy.
5) People with other medical conditions, such as high blood pressure and high cholesterol, are at greater risk for developing diabetic retinopathy.
6) Pregnant women have a higher risk for developing diabetes and diabetic retinopathy.
7) When gestational diabetes occurs, there is a much higher risk of developing diabetes over time.
Your action plan for this week is to research HEDIS scores for diabetes, then review your office protocols for diabetic patients. Make sure the following six actions are occurring in your office for your patients with diabetes and that you are documenting each of these appropriately in the patient record.
1) A yearly dilated fundus examination is occurring for all diabetics.
2) A letter is sent to the primary care physician (PCP) containing: that a dilated fundus exam (DFE) occurred, the date of the DFE, and the results of the DFE.
3) Document the most recent blood pressure (BP) in the patient record. It needs to be less than 140/90.
4) Document in the medical record the date when the last HbA1c test was performed and the result. If it has been over a year since the patient has had an HbA1c test, either schedule the patient for one or schedule a patient visit with the PCP for the test.
5) Document in the medical record the date when the last LDL-C test was performed and the result. If it has been over a year since the patient has had an LDL-C test, either schedule the patient for one or schedule a patient visit with the PCP for the test.
6) Document in the medical record the date when the last urine microalbumin test was performed and the result. If it has been over a year since the patient has had a urine microalbumin test, either schedule the patient for one or schedule a patient visit with the PCP for the test.
Don’t forget that Medicare allows an eye examination for diabetes at least one time per year. All people with Medicare Part B are covered.
