Adminasplain

[Lordosis]

Don't you love when somebody with no medical background tries to explain medicine to you.

I got roped into some meeting about quality metrics and I raised the point about patients being on panels that were inappropriate. The example I gave his somebody was marked a diabetic when they clearly were not a diabetic and they were flagged for needing a hemoglobin a1c. The administrator in the room suggested that we just ordered hemoglobin a1c to get them off the list.

[ENT Doc]

What an idiot. All the more reason incorporating the risk of being the payer into the provider side of the equation makes sense. If your hospital/ACO were the one collecting premiums and taking an increased risk for health management (Kaiser model) their response would be the exact opposite (and appropriate).

[nephron]

I see people labelled as diabetics who I don't think are diabetics all the time. Some are taking oral hypoglycemics with a1c's in the 5's. I'm not sure what their primary care doctors are doing, maybe they were diabetic, got better and just got left on their medications? I usually don't address it unless the medication needs to be adjusted for renal failure. Anyways, with the metric of A1C for diabetics being below a certain range, there probably is an incentive to keep labeling people as diabetic even when they no longer are. Probably an incentive not to check your super non-compliant patients A1C too because you get a higher number who have a1c greater then whatever the quality metric is.

[Lordosis]

I see people labelled as diabetics who I don't think are diabetics all the time. Some are taking oral hypoglycemics with a1c's in the 5's. I'm not sure what their primary care doctors are doing, maybe they were diabetic, got better and just got left on their medications? I usually don't address it unless the medication needs to be adjusted for renal failure. Anyways, with the metric of A1C for diabetics being below a certain range, there probably is an incentive to keep labeling people as diabetic even when they no longer are. Probably an incentive not to check your super non-compliant patients A1C too because you get a higher number who have a1c greater then whatever the quality metric is.

At least with our metric not checking every 6 months leads to failing. So even if I know some one is going to fail it is not a disincentive to check. But yes aggressive labeling might help. But what a hassle

[EntrepreneurMD]

Per Medicare and insurers, once a diabetic always a diabetic. So if a diabetic undergoes gastric bypass surgery for example, no longer on diabetic medications and has had normal sugars for years - they are still considered diabetic and will remain on those panels requesting regular A1C's, urine microalbumins, diabetic eye exams, statin therapy etc. Medicare Advantage plans and ACO's are notorious for highlighting this. They're on the panel in the first place because someone in the past labeled them diabetic, maybe a former PCP, a hospital, a nursing home, etc.

Often, if you go back and ask the patient they'll let you know they were on diabetic medication at some point in the past. They are therefore controlled diabetics, hence normal fasting blood sugars and A1C's at this point.

If the diagnosis was truly erroneous from the beginning, I don't think anyone knows how to actually get this expunged from the record. I wish Medicare would provide clarity here.

Diabetes is not the only issue, there are others. For example, a hypertensive patient getting their blood pressure medication for free/discounted cash pricing (at a grocery or Wal-Mart pharmacy) may not get the prescription run thru insurance (which may allow for a copayment) and that patient shows up as failing the compliance measure since the insurer does not have the fill record. I think the insurers have been working with the pharmacies on this one to still run thru the insurer, but I occasioanlly run into this.

In some areas you can report exemptions to the performance measure. Examples include colectomy patients for the colon cancer screening measure, bed bound (not wheelchair) patients for the fall measure, influenza vaccine refusal or allergy, statin intolerance and so on.

The system will likely never be perfect.

[EntrepreneurMD]

I see people labelled as diabetics who I don't think are diabetics all the time. Some are taking oral hypoglycemics with a1c's in the 5's. I'm not sure what their primary care doctors are doing, maybe they were diabetic, got better and just got left on their medications? I usually don't address it unless the medication needs to be adjusted for renal failure. Anyways, with the metric of A1C for diabetics being below a certain range, there probably is an incentive to keep labeling people as diabetic even when they no longer are. Probably an incentive not to check your super non-compliant patients A1C too because you get a higher number who have a1c greater then whatever the quality metric is.

Per guidelines, the patients only have to be diagnosed once (accurately) and will always be considered diabetic regardless of control. Remember diet and exercise/weight loss are considered first line treatment for diabetes. So controlled numbers without medications doesn't mean no treatment.

If you're part of an ACO or take Medicare Advantage plans they can clarify this for you.

[childay]

#quality

[Cubicle]

Per Medicare and insurers, once a diabetic always a diabetic.

I run into this several times per week. "Were" diabetics, sent from their PMDs, on Metformin with a 5.1 a1c, letters from insurances "requesting" I discuss their diabetes with them... Plus I think there is more money as they (the patients) are permanently sicker, so more $$$ to be made/spent on their care.

[Lordosis]

The unfortunate fact is the vast majority of diabetics do not get better. It is an odd thing when someone is able to change their lifestyle and reverse the changes. I have had a few very successful people and a few more moderately successful.
for those few I am willing to take a small metric hit if needed. But if the diagnosis was erroneous that is just dumb. I feel there are more misdiagnosed diabetics then recovered diabetics.

[EH]

There needs to be a way to take people off the list - we can do this we just need to document why. Lots of people end up on it erroneously (most commonly for me prior labs didn’t justify the diagnosis or it was somehow coded in hospital).