Diabetes Provider Recognition Certification Process
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Overview and Lessons Learned

 www.ncqa.org/dprp

 

Mission Statement:

Concern over the cost and quality of healthcare services in the United States over the past several years has resulted in increased demand for accountability.  This call for accountability, coming from patients and payers, has led to the development of many initiatives involving the use of performance and outcomes measures to encourage the delivery of high quality health care services.  Such factors led the American Diabetes Association (ADA) and the National Committee for Quality Assurance (NCQA) to implement the Diabetes Physician Recognition program.    Goals of recognition include improving the care given to people with diabetes, raising the bar for performance, motivating other physicians and groups to document and improve the delivery of care, and generating referrals to the provider.

 

Program Criteria:

To support these goals, the Diabetes Physician Recognition Program assesses physicians on their performance on 12 key measures of care for adult patients and 8 key measures of care for pediatric patients.  In order to "“pass” any one measure, a proportion of the diabetes patients must have received/achieved the measure.     The physician does not have to “pass” every measure to achieve recognition; they only need to pass enough measures to meet the criteria (see attachment for specific criteria and point breakdown).  There is also a optional patient survey that may be administered to the patient at the office or sent to their home. Recognize that the points necessary to “pass” increase if the survey is used.  Many groups have found that opting to use the survey has increased their performance rates and points earned as patients generally respond favorable. 

 

Eligible Participants:

Physicians who provide direct, face-to-face continuing care for at least 25 diabetic patients in a 12-month period may apply for recognition.  The eligible 25 diabetic patients must meet 3 criteria: 1) the patient must be 5 years of age or older, 2) the patient must have had a diagnoses of diabetes for 12 months and, 3) the patient must have been under the care of the provider for at least 12 months.  A group of physicians (6+) may also apply for recognition if each physician meets the above criteria. The physicians would then need to complete a chart review of 200 patient charts to apply for recognition.

 

Process of Selecting Patient Sample:

Every individual provider or group must construct a patient log, identify eligible diabetes patients and collect data.  The groups may identify eligible patients via an administrative data system or as they present for care. 

 

There are two methods of data collection approved by the ADA.  Physicians and groups should choose the method that is the best fit for their practice based on the following 3 assumptions

1)      the amount of time the PCP/ group is willing to earmark for this process i.e., do they have supporting staff that can dedicate time to the process?

2)      the time frame in which the group/PCP  would like the process completed i.e., does this need to be completed sooner rather than later?

3)      Does a sample chart review (n=5) demonstrate the providers performance is at the level at which they would meet the criteria?  This baseline analyses should determine readiness and or need of implementation of processes prior to application.

 

Prospective Data Collection Method:

The first data collection method, the prospective data collection method is the choice of collection by the ADA as it focuses on identifying and collecting data on patients as they present for care.  The physician and office staff identify eligible patients (criteria stated above) complete a form and administer the optional survey at the time in which the patient presents.   The medical chart review form would then be stored and entered into the ADA software program when the PCP had seen and recorded data on 25 patients.

 

There are several advantages to using this method of identification including reduction in provider staff time involved, ease of medical record abstraction and good patient survey response (if administered). The speed at which 25 charts is obtained and completed depends on the number of diabetic patients seen by the physician daily.  

 

Retrospective Data Collection Method:

The second data collection process includes the applicants selecting a start date, and then consecutively identifying diabetes patients who meet the Patient Eligibility Requirements and have had patient visits prior to this date.  Because this is a sample of patients already seen, the data collection period is the twelve-month timeframe preceding and including the most recent visit for the patient.

 

Retrospective data collection requires a dedicated staff member to pull charts and review records at times other then when seeing patients. If a group uses both paper charts and electronic data systems each patients data review will need to include both sources of information, thus increasing the time in which it takes to complete.

 

Program Fees:

There is a $60 charge for the application and materials. Individual physicians applying costs $360 ($60 application and $300 when submitting the application). A group applicant of 6 or more physicians costs $2700. Groups applying for recognition, must pre-pay $60 to obtain the program materials.  The remaining cost will be paid when submitting the application. All Program fees are nonrefundable.

 

Staff Involvement: 

The data collection method could be managed by an individual PCP, but would be best supported by an office staff member who would identify the eligible patients as they presented for care, prepare the medical chart review form and patient survey, enter the data collected and complete the application.

 

The ADA suggests the PCP and office staff should expect at least 15 minutes to abstract the medical record for each patient in the sample.  For example, the ADA suggests that the preparation of an application package for one physician applicant with a data sample of 25 patients is approximately 10 hours (application: 1 hour; medical record abstraction: 3-minutes x 25 patients = 7.5 hours).   However, this does not account for the hours spent contacting ophthalmologists to receive notes of dilated eye exams (if not found in the chart) or the time in which it takes to enter the data and coordinate the application (5+ hours). In reality the application process will take twice as long as the ADA suggests approximately 20 hours per PCP.

 

 

 

Impact of Certification:

With the achievement of recognition providers will 1) be able to identify areas of practice that vary from appropriate performance criteria for treatment of people with diabetes, thus providing opportunities for quality improvement 2) be recognized by the public and their professional peers as providers of quality diabetes care through posting of their achievement on the ADA web site and through press release and 3) in some cases receive monetary rewards.  The economic benefits include using ADA recognition status as a means of demonstrating that they provide quality diabetes care when contracting with health plans and purchasers of health services and also receive referrals of consumers seeking a physician through ADA’s 1-800-DIABETES National Call Center.
Attachment:

American Diabetes Association Physician Recognition Program Measures for Adult Patients

Required Measures	Goal	Points
Proportion w/ HbA1c < 7%*	40%	10.0
Proportion w/ HbA1c >9%*	£15%	15.0
Eye exam*	60%	10.0
Foot exam	80%	5.0
Proportion >140/90 mm Hg*	£35%	15.0
Proportion <130/80 mm Hg*	25%	10.0
Nephropathy assessment*	80%	5.0
Proportion with LDL <100 mg/dl*	36%	10.0
Proportion with LDL >130 mg/dl	£37%	10.0
Smoking Status and Cessation Advice or Treatment	80%	10.0
Total Points		100.0
Points to Achieve Recognition		75.0
Optional Patient Survey Measures	Goal	Points
Tobacco status & counseling	76%	10.0
Self-management education	90%	10.0
Medical nutrition therapy	90%	10.0
Self-monitoring of blood glucose:   - non-insulin treated patients	50%	1.0
- insulin treated patients	97%	4.0
Patient satisfaction with:   - diabetes care overall   - diabetes questions answered   - access during emergencies   - explanation of lab results   - courtesy/personal manner of provider	58% 56% 46% 50% 77%	1.0 1.0 1.0 1.0 1.0
Total Points (including Required Measures)		110.0
Points to Achieve Recognition		80.0

Notes:

*Consistent with HEDIS measures