Diabetes is a complex chronic illness that requires monitoring on an ongoing basis. Currently, more than 23 million Americans are diagnosed with diabetes.1 The Centers for Disease Control shows diabetes as the 7th leading cause of death in the United States. In Maine approximately 142,000 people, or 11.5% of the adult population, have diabetes and 386,000 people, 37.2% of the adult population, have prediabetes with blood glucose levels higher than normal, but not yet high enough to be diagnosed as diabetes.2


Diabetes is expensive. In 2017, it accounted for $237 billion in direct medical costs.3 Diagnosed diabetes costs an estimated $1.4 billion in Maine each year. People with diabetes have medical expenses approximately 2.3 times higher than those who do not have diabetes and a myriad of co-existing conditions that contribute to these costs.The serious complications include heart disease, stroke, amputation, end-stage kidney disease, blindness – and death.5


Since diabetes HbA1c testing is a key measure to assess for future medical conditions related to complications of undiagnosed diabetes, the National Commission for Quality Assurance (NCQA) requires health plans to review claims for diabetes in patient health records and the findings contribute to health plan Accreditation levels and the Quality Rating System (QRS) measurement for Marketplace plans. A systematic sample of patient records is pulled annually as part of the HEDIS® medical record review to assess for documentation.


What is the HEDIS measure?

The diabetes measures focus on members 18-75 years of age with diabetes (type 1 and type 2) who had each of the following assessments:


  • Hemoglobin A1c (HbA1c) testing
  • HbA1c poor control (>9.0%)
  • HbA1c control (<8.0%)
  • Dilated retinal exam
  • Medical attention for nephropathy


Each year NCQA reviews the measures and makes changes in accordance with technological or medical improvements. This year, NCQA also has updated the approach to allow for more administrative methods to collect the measure and added telehealth encounters to satisfy certain components of the measure. One of two patient visits may be a telehealth visit, a telephone visit or an online assessment. When documenting patients’ records, use the telehealth code from CPT II codes in combination with the diabetes diagnoses.


Continued management and diverse pathways to care are essential in controlling blood glucose and reducing the risk of complications. While it is extremely beneficial for the patient to have continuous management, it also benefits our providers. As HEDIS rates increase, there is potential for the provider to earn maximum or additional revenue through Pay for Quality, Value Based Services, and other pay-for-performance models.6


Sources include:

− Diabetes Prevalence: 2015 state diagnosed diabetes prevalence, cdc.gov/diabetes/data; 2012 state undiagnosed diabetes prevalence, Dall et al., ”The Economic Burden of Elevated Blood Glucose Levels in 2012”, Diabetes Care, December 2014, vol. 37.

− Diabetes Incidence: 2015 state diabetes incidence rates, cdc.gov/diabetes/data

− Cost: American Diabetes Association, “Economic Costs of Diabetes in the U.S. in 2017”, Diabetes Care, May 2018.

− Research expenditures: 2017 NIDDK funding, projectreporter.nih.gov; 2017 CDC diabetes funding, www.cdc.gov/fundingprofiles








Featured In:
May 2019 Anthem Maine Provider Newsletter