"The two words ‘information’ and ‘communication’ are often used interchangeably, but they signify quite different things. Information is giving out; communication is getting through." -- Sydney J. Harris

Driving Change in Diabetes Care


NOTE: This is the first article in a year-long series highlighting the notable achievements and milestones of MN Community Measurement in celebration of our 10th anniversary. Read more about our history in Our Story.

Approximately 21 million Americans live with diabetes. It is one of the leading causes of death and disability in Minnesota and nationally. It cost Americans about $245 billion in 2012. And it results in immeasurable personal costs for patients with poorly-controlled diabetes who often develop nerve damage; have diminished or lost eye sight; suffer from kidney and heart disease; and have strokes.

The personal, economic and societal costs of diabetes are staggering – making it clear why ensuring patients with diabetes receive high-quality care to control and manage their condition is critical. And why MN Community Measurement (MNCM) made diabetes care one of our first measurement priorities more than a decade ago.

From that time, the improvement in care of patients with diabetes has been astounding. In 2004, only four percent of adult patients with diabetes had their condition well controlled; in 2014, that amount is 39 percent. While there continues to be significant room for improvement, the nearly tenfold increase in the percentage of Minnesotans receiving high-quality care for diabetes would not have been accomplished without public reporting to accelerate the pace.

An innovative approach
In 2000, the idea that would evolve into MN Community Measurement was in its earliest stages. The medical directors of three large Minnesota’s health plans came together with the desire to create a single, combined report that would compare patient care and outcomes across Minnesota. Each organization was gathering some data, but none were comprehensive or easily comparable. They quickly focused on diabetes as the place the start.

Other community leaders soon agreed to join this effort and, in 2002, and the Minnesota Council of Health Plans (MCHP) launched the Minnesota Community Measurement Project to make the idea into reality.

Progress came quickly. Led by MCHP’s Julie Brunner and a leadership team, the Optimal Diabetes Care measure was created, which utilized the pioneering approach of reporting five key components of diabetes care into an “all-or-none” composite measure. These five indicators, dubbed “the D5,” now include:

  • Blood pressure less than 140/90 mmHg
  • LDL or “bad” cholesterol less than 100mg/dl
  • Blood sugar (A1c) less than 8%
  • Being tobacco free
  • Taking an aspirin daily, if appropriate

“We wanted to focus beyond blood sugar and really look at heart risk, which is core to our diabetes composite measure,” explained MNCM President Jim Chase. “We aimed for the completeness of care because we really wanted to create an impact around cardiovascular risk for our diabetes patients.”

Processes were created to aggregate claims data from seven health plans and report the results by medical group. In January 2003, the project produced its first performance report that looked at diabetes care provided in 2001. It included information on 49 medical groups. The first report was only made available to the medical groups – they could each see their performance and where they stood in comparison to the other 48 groups, but the competitive results were blinded.  While not fully transparent, that inaugural report made it possible for medical groups to understand their results in the context of their peers and focus their improvement work. It leveled the playing field.

Later that same year, in October 2003, a second report was shared with medical groups – this one included Optimal Diabetes Care, as well as seven Healthcare Effectiveness Data and Information Set (HEDIS) measures. It looked at care provided in 2002. Like the first report, the results were blinded but allowed the medical group to see where they stood.

The project had always intended to share the information with the public, with the expectation that doing so would increase accountability and improve care. After establishing trust and validating results and processes with the first two reports, MNCM publicly reported its first quality performance data in 2004 for care provided in 2003. It included performance results for 51 medical groups on 16 measures, including asthma, mental health,  diabetes, high blood press and women’s and children’s health care.

While not directly comparable to the Optimal Diabetes Care rates produced today (due to data source and measure specification changes over the years), our first report in 2004 revealed only four percent* of adult patients with diabetes had all five elements under control.

Steady improvement and expanding reach
As MNCM evolved from a project to an independent, non-profit organization in 2005 and expanded its measurement work, our pioneering approach to measuring diabetes care continued to lead the way.

Steady improvements in the care of patients with diabetes could be seen through MNCM’s annual Health Care Quality Report – from four percent* in 2004 to six percent* in 2005 to ten Diabetes 2004-2014percent* in 2006.

The diabetes performance data was so robust and credible that health plans and the Buyers Health Care Action Group (now Minnesota Health Action Group) began using it in pay-for-performance programs in 2006. Medical groups were able to show how well they performed in comparison with their peers; those with the highest quality care earned rewards.

By this time, many medical groups were aggregating data from their medical records on diabetes and vascular care for internal improvement efforts aligned with MNCM measures. Medical group leaders encouraged MNCM to develop a method that would utilize data directly from their records rather than relying solely on health plan claims data. Medical record data had the advantage of being timelier; reflecting care for all patients, including those not insured; and would allow performance results to be reported by clinic sites.

From this, the MNCM Data Portal and Direct Data Submission process were born – a secure online process and infrastructure for medical groups to submit data from their medical records to MNCM and then view results and utilize reports on their performance. The result was MNCM’s first-ever public reporting of performance measures by clinic site. The Optimal Diabetes Care measure led the way once again, as one of only two measures reported at that level with information on 191 clinics across Minnesota. This allowed medical groups and patients to see variation even among practices in the same medical group.

Additionally, as clinical guidance on diabetes evolved, so did MNCM’s Optimal Diabetes Care measure. In both 2007 and 2010, measure targets were adjusted to align with the Institute for Clinical Systems Improvement’s guidelines. We also began to utilize the data that had been collected in different ways, such as evaluating differences in care by socioeconomic status in the Health Care Disparities Report for Minnesota Health Care Programs.

Nationally recognized
As the usefulness of MNCM’s Optimal Diabetes Care measure began to expand, national organizations became interested in the work being done in Minnesota.

Beginning in 2008, the Robert Wood Johnson Foundation selected Minnesota as one of 16 sites for its groundbreaking Aligning Forces for Quality program, with MNCM as the state’s lead organization. Due in part to the gains we’d already made in diabetes care, larger improvements in and patient engagement around diabetes were some of the main focuses of the alliance’s work over the past six years.

In 2010, the diabetes measure became MNCM’s first measure to be endorsed by the National Quality Forum, considered the gold standard for health care measurement in the United States. Over the next two years, the measure was accepted into the Center for Medicare and Medicaid Services (CMS) Physician Quality Reporting System (PQRS) and Accountable Care Organization (ACO) measurement programs.

And in 2012, Consumer Reports partnered with MNCM to publish a special supplement for their Minnesota subscribers focused on high-quality diabetes and cardiovascular care. It included ratings of 552 clinics statewide, as well as an analysis of Metro-area medical groups focused on the cost and quality of health care.

“Good information on health care quality should be readily available to everyone,” Chase said of the partnership. “Consumer Reports can get more people to see these measures, and help them understand how to use them to get better care.”

Throughout this period, the percentage of Minnesotans receiving high-quality diabetes care continued to increase – rising from 17 percent in 2008 to 38 percent in 2012.

Advancing the future
As clinical guidelines for optimal care evolve, so must the way we measure that care. MNCM employs thoughtful and deliberate planning and implementation when guideline changes call for measure revisions, as was the case for the cholesterol component of our Optimal Diabetes Care and Optimal Vascular Care measures last year.

In late 2013, the American College of Cardiology and American Heart Association released new guidelines for the management of cholesterol. MNCM convened a workgroup to determine the new guidelines’ impact on the diabetes and vascular measures. In fall 2014, the workgroup presented a redesigned cholesterol component, which aligned with the new guidance; the redesigned component will be part of the Optimal Diabetes Care measure beginning in report year 2016 evaluating 2015 dates of service.

In 2014, 39 percent of Minnesotans with diabetes met all five measurement goals to have their condition optimally managed. The significant improvement in this rate has a ripple effect, as related complications have also decreased over time. For instance, in 2010, HealthPartners health plan found that its 32,102 members with diabetes suffered 387 fewer heart attacks, received 69 fewer leg amputations and developed 777 fewer ocular complications than previous years.[1]

“We’re seeing changes at the population and individual patient levels,” Chase said. “The composite model captures more critical data during a single visit so you’re less likely to lose people through the cracks because one practice checked for cholesterol while another did not.”

With about 300,000 Minnesotans currently living with diabetes and 20,000 Minnesotans being newly diagnosed every year, our community still has plenty of work left to do to make sure everyone is getting high-quality care so their diabetes is well managed. But the past decade has shown we’re more than up to the challenge.

[1] “Composite Measures: A New Gold Standard in Diabetes Care.” Aligning Forces for Quality. March 2014.

* These statewide averages were recast after measure targets were adjusted in 2007 to align with changing clinical guidance. The original averages were 12 percent in 2004, 16 percent in 2006, and 20 percent in 2007.