Dr. Allen Fein, a family practice physician who himself has diabetes, describes how National Committee for Quality Assurance (NCQA) recognition changed how he cares for patients with diabetes.
Organization: Family Practice
Location: Southampton, NY
Number of Patients: Small
In your view, what are the most important measurements of quality care required by the NCQA Diabetes Recognition Program?
The HgbA1C is a very important and effective measurement that reliably informs the patient and the physician about the bottom-line of glucose control for the previous few months. Too often patients “behave” for a few days before office visits and lab tests, to quickly but temporarily improve their weight, blood pressure, and fasting blood glucose, for the record! The patient’s blood pressure is also very important because it has been established that blood pressure control is more important than glucose control, in the long term for patients with diabetes.
How will NCQA recognition help you enable better care for diabetes patients? Are there any specific positive changes in patients’ health outcomes that you are now expecting to see?
After focusing repeatedly on the targets of the NCQA program, the physician should more easily seek out and implement the targets in diabetic patients. Patients with diabetes make multiple visits to a physician, and while dealing with the myriad of their presenting complaints, it is important to step back and efficiently check on the “big picture” every 6 – 12 months. Preparing for the NCQA recognition helps the physician cement good habits. It is not usually the patient who is going to initiate such diabetes quality care overviews!
Diabetes is not the kind of disease where patients come running back to thank the physician for great outcomes, because the complications of diabetes are somewhere out in the vague future. Efforts to get patients to meet targets usually require much effort at dieting, active exercise, smoking cessation, and often new medications. These are not simple, permanent, quick fixes that patients want and often expect.
Some patients will be happy to share stories about having more energy and having to spend less time day and night running to the bathroom, and many will be happy to reach their target numbers (BP, HgbA1C, LDL, etc). I believe that as we stay with our diabetic patients over the decades, and see that they have avoided problems, while their friends and family end up with serious illnesses, there will be a significant delayed gratification enjoyed by all.
Did compiling the data for NCQA’s evaluation help you better organize your patients’ information, or did you already have an electronic record system in place?
Every 6 -12 months, I am now making the effort to include in the patient’s progress notes, a review of where the patient stands vis-a-vis the target numbers, and to determine changes needed. It is too easy to forget about these specific targets while putting out the many fires diabetic patients are always coming in and out of the office and hospital with. Thanks to a hospital/government initiative, we plan to go paperless (NextGen) in the near future, which should make thing easier for us to manage our diabetic patients.
In what ways did you have to adjust policies or practices in order to achieve NCQA recognition?
Initially, I reviewed my diabetic patient medical records, and contrary to what I had expected, it was clear that I was quite far from meeting NCQA goals. Being a diabetic myself, I was familiar with and supported such target goals. I had thought that my patients were getting very good care, so this was quite an eye-opener for my staff and to me personally.
My office subsequently made diabetes care a priority. All diabetic charts were pulled and each chart reviewed. We basically badgered all our diabetic patients to come in for focused diabetic care visits. Those patients who were non-compliant were called and sent letters letting them know that they were overdue for a visit, and were advised to schedule an appointment in order to maintain their active patient status with me. We then evaluated all such patients for the target goals, and made the appropriate interventions, including timely follow-up with us.
A lot of effort was made assisting patients to set up visits with specialists for dilated eye examinations. We learned that the requirement by NCQA to have in the patient record written proof of dilated eye exam, rather than a simple statement from the patient attesting to such examination, was worthwhile, in that many of our patients who had claimed to have had such important examinations done, actually had not had them done! We felt that there may have been a little impatience from specialists about all our phone calls, but after personally speaking with the specialists about the NCQA program, and the importance of getting the dilated examinations done, there was good cooperation.
In your opinion, what is the overall value of recognition programs for diabetes care? Do they encourage providers to adhere to the most updated standards or routines? Does such recognition make it easier to remember to perform needed tests or take certain measurements?
The preparative groundwork done by my office staff and by myself was eye-opening. We were quite surprised as to how many of our patients with diabetes were not even being evaluated for the diabetic targets, and how many of those tested were not at target. We were surprised that many patients with diabetes had been lost to follow-up. The teaching materials provided to me by the NCQA program were excellent, up to date, and also provided free accredited CME. It was very satisfying to my office staff, my patients, and myself, to see the fruits of our labor a year later, when it was clear that we were well on top of the diabetic patient targets. In the end, we breezed through the NCQA recognition requirements.
While there was a significant cost to the practice in participating with the NCQA program, from many uncompensated hours of reviewing charts and collecting the data, there were also many office visits generated that otherwise would have not occurred. There was also a generosity of help and encouragement from the New York Academy of Family Physicians, and even an offer to come to my office to help go through the charts to collect the data, a service which we never ended up needing, once we realized how simple and easy it was to enter the data into their flow-chart.
I have since led a CME workshop on diabetes with my peers (which paid me $500!), and in January, 2011, I will lead a module on diabetes for Family Physicians (which will give me two free nights at a ski resort!), so there have indeed been personal unexpected gratifications to the many hours invested in beefing up my diabetes skills, beyond earning the certificate and having well cared for patients.
Subsequently to my earning the NCQA recognition, there have been a few articles and announcements in the local press about this. A few patients have since congratulated me, but so far, there has not been a stampede of new diabetic patients coming through my door! I am unaware of any excitement by the health insurance plans that I work with, to inform their members about this accomplishment, nor am I aware of any financial reward or incentive by any of the insurance companies for such NCQA recognition. I certainly didn’t do this for the money anyway; as a physician with diabetes, it was personally important for me to participate in this valuable program. I had looked into this recognition a couple of years ago, but was turned off by the high application fee. Now, thanks to grants, signing on to this program through the New York Academy of Family Physicians did not cost me anything.
Any final thoughts?
I recommend that my colleagues join in participating in this valuable and rewarding initiative.