Managing Diabetes
Health Plan Coverage of Services and Supplies Gao ID: GAO-05-210 February 25, 2005Diabetes, which afflicts millions of Americans, is a manageable disease whose effects can be mitigated with proper care, regularly received. Experts recommend certain services and supplies for managing diabetes. Because these can be costly, concerns exist about whether individuals with diabetes have access to and receive what they need. Little is known, however, about health plan coverage of diabetes services and supplies. GAO reviewed the extent to which (1) states require insurance policies to cover diabetes services and supplies, (2) health coverage not subject to state requirements includes diabetes services and supplies, and (3) individuals with diabetes ages 18 and older receive services and supplies. GAO analyzed all 50 states' and the District of Columbia's laws and regulations pertaining to diabetes coverage. GAO also obtained from selected health plans providing coverage not subject to state requirements--13 large-employer plans and 3 plans in the Federal Employees Health Benefits Program (FEHBP)--information on coverage of 10 services and nine supplies identified as important for individuals with diabetes. In addition, GAO obtained national data from the Centers for Disease Control and Prevention (CDC) on individuals' receipt of diabetes services and supplies. GAO received technical comments from CDC and incorporated them in the report as appropriate.
In 2004, 47 states, including the District of Columbia, had laws or regulations related to coverage of diabetes services or supplies, although specific requirements varied by state. Services for which states most often required coverage were diabetes education (45 states) and medical nutrition therapy (27 states). All 47 required coverage of diabetes supplies, although some states were more specific than others about which supplies must be covered. Health plans GAO contacted that provide coverage not subject to state insurance requirements--those offered by 13 large Fortune 500 companies and the 3 largest health plans in FEHBP--covered most of the services and supplies recommended for individuals with diabetes, generally without limits on the coverage. Each plan covered at least 7 of 10 diabetes services, such as an annual blood glucose test, cholesterol and blood pressure monitoring, and influenza vaccinations, as well as at least five of nine diabetes supplies, such as insulin and insulin-administering supplies. According to a 2003 CDC nationwide survey, the majority of individuals with diabetes reported receiving at least one diabetes service within the past 12 months. Significantly fewer individuals, however, reported receiving five services that individuals with diabetes are recommended to receive at least once a year. For example, an estimated 88 percent reported receiving a test for blood glucose, whereas an estimated 33 percent had received the five recommended services: blood glucose and cholesterol tests, eye and foot exams, and an influenza vaccination. Receipt of diabetes services and supplies varied by service, state, and whether an individual had health coverage. For example, 71 percent of individuals with diabetes who had health coverage at the time of the survey received eye exams, compared with 46 percent of individuals with diabetes who lacked coverage.
GAO-05-210, Managing Diabetes: Health Plan Coverage of Services and Supplies
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
February 2005:
Managing Diabetes:
Health Plan Coverage of Services and Supplies:
GAO-05-210:
GAO Highlights:
Highlights of GAO-05-210, a report to congressional requesters:
Why GAO Did This Study:
Diabetes, which afflicts millions of Americans, is a manageable disease
whose effects can be mitigated with proper care, regularly received.
Experts recommend certain services and supplies for managing diabetes.
Because these can be costly, concerns exist about whether individuals
with diabetes have access to and receive what they need. Little is
known, however, about health plan coverage of diabetes services and
supplies.
GAO reviewed the extent to which (1) states require insurance policies
to cover diabetes services and supplies, (2) health coverage not
subject to state requirements includes diabetes services and supplies,
and (3) individuals with diabetes ages 18 and older receive services
and supplies. GAO analyzed all 50 states‘ and the District of
Columbia‘s laws and regulations pertaining to diabetes coverage. GAO
also obtained from selected health plans providing coverage not subject
to state requirements”13 large-employer plans and 3 plans in the
Federal Employees Health Benefits Program (FEHBP)”information on
coverage of 10 services and nine supplies identified as important for
individuals with diabetes. In addition, GAO obtained national data from
the Centers for Disease Control and Prevention (CDC) on individuals‘
receipt of diabetes services and supplies. GAO received technical
comments from CDC and incorporated them in the report as appropriate.
What GAO Found:
In 2004, 47 states, including the District of Columbia, had laws or
regulations related to coverage of diabetes services or supplies,
although specific requirements varied by state. Services for which
states most often required coverage were diabetes education (45 states)
and medical nutrition therapy (27 states). All 47 required coverage of
diabetes supplies, although some states were more specific than others
about which supplies must be covered.
Health plans GAO contacted that provide coverage not subject to state
insurance requirements”those offered by 13 large Fortune 500 companies
and the 3 largest health plans in FEHBP”covered most of the services
and supplies recommended for individuals with diabetes, generally
without limits on the coverage. Each plan covered at least 7 of 10
diabetes services, such as an annual blood glucose test, cholesterol
and blood pressure monitoring, and influenza vaccinations, as well as
at least five of nine diabetes supplies, such as insulin and insulin-
administering supplies.
According to a 2003 CDC nationwide survey, the majority of individuals
with diabetes reported receiving at least one diabetes service within
the past 12 months. Significantly fewer individuals, however, reported
receiving five services that individuals with diabetes are recommended
to receive at least once a year. For example, an estimated 88 percent
reported receiving a test for blood glucose, whereas an estimated 33
percent had received the five recommended services: blood glucose and
cholesterol tests, eye and foot exams, and an influenza vaccination.
Receipt of diabetes services and supplies varied by service, state, and
whether an individual had health coverage. For example, 71 percent of
individuals with diabetes who had health coverage at the time of the
survey received eye exams, compared with 46 percent of individuals with
diabetes who lacked coverage (see figure).
Estimated Percentage of Individuals Ages 18 and Older with Diabetes,
With and Without Health Coverage, Who Reported Receiving Diabetes
Services, 2003:
[See PDF for image]
[End of figure]
What GAO Recommends:
www.gao.gov/cgi-bin/getrpt?GAO-05-210.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Kathryn G. Allen at (202)
512-7118.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Most States Require Insurance Policies to Cover Diabetes Services and
Supplies, Although Specific Requirements Vary:
Selected Health Plans Providing Coverage Not Subject to State
Regulation Cover Most but Not All Diabetes Services and Supplies:
Nationwide, Receipt of Diabetes Services and Control of Related Health
Conditions Are Uneven:
Agency Comments:
Appendix I: Scope and Methodology:
Appendix II: Summary of Diabetes Coverage Requirements in State Laws or
Regulations, 2004:
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
Acknowledgments:
Tables:
Table 1: Services for Managing Diabetes:
Table 2: Diabetes Services Covered by the Three Largest FEHBP Plans,
2004:
Table 3: Range among States in Estimates of Diabetes Services Received
by Individuals with Diabetes, 2003:
Table 4: Indicators of Services and Supplies for Managing Diabetes:
Figures:
Figure 1: Number of States Requiring Coverage of Diabetes Services and
Supplies, 2004:
Figure 2: Diabetes Services Covered by 13 Large Employers' Self-Funded
Health Plans, 2004:
Figure 3: Diabetes Supplies Covered by 13 Large Employers' Self-Funded
Health Plans, 2004:
Figure 4: Estimated Nationwide Percentage of Individuals Ages 18 and
Older with Diabetes Who Reported Receiving Diabetes Services, 2003:
Figure 5: Estimated Nationwide Percentage of Individuals Ages 18 and
Older with Diabetes, With and Without Health Coverage, Who Reported
Receiving Diabetes Services, 2003:
Abbreviations:
ADA: American Diabetes Association:
Alliance: National Diabetes Quality Improvement Alliance:
BRFSS: Behavioral Risk Factor Surveillance System:
CDC: Centers for Disease Control and Prevention:
ERISA: Employee Retirement Income Security Act of 1974:
FEHBP: Federal Employees Health Benefits Program:
NHANES: National Health and Nutrition Examination Survey:
OPM: Office of Personnel Management:
United States Government Accountability Office:
Washington, DC 20548:
February 25, 2005:
The Honorable Joe Barton:
The Honorable Fred Upton:
House of Representatives:
Diabetes afflicts an estimated 18 million Americans, and the number of
newly diagnosed cases has been rising, according to the Centers for
Disease Control and Prevention (CDC).[Footnote 1] Diabetes is
characterized by a high level of blood glucose, which damages nerve
endings and blood vessels; this damage in turn leads to serious health
complications such as blindness, heart disease and stroke, kidney
disease, and poor circulation in the extremities potentially resulting
in foot or leg amputations. Complications like these can be delayed or
prevented with proper care, provided that such care is accessible and
used.[Footnote 2] Specifically, federal health agencies and national
organizations recommend that individuals with diabetes receive certain
services to manage their disease--including periodic tests for blood
glucose,[Footnote 3] eye and foot exams, medical nutrition therapy, and
diabetes education--along with other services, such as cholesterol
tests, smoking cessation services, and influenza immunizations, which
help reduce the risk of complications. Supplies that many individuals
with diabetes use to track and control their blood glucose levels
include blood glucose monitors; test strips; insulin; and, to
administer insulin, insulin pumps or disposable needles and syringes.
Because diabetes services and supplies can be costly, you and others
have raised concerns about whether individuals with diabetes have
access to and receive all the services and supplies they need. Certain
national organizations concerned with diabetes patient care have
advocated state laws mandating that health insurance cover certain
services and supplies benefiting these individuals. Although states
generally do not regulate employment-based benefit plans, such as
health plans provided by employers, they do regulate insurance;
consequently, health coverage employers provide through the purchase of
insurance is generally subject to state insurance regulation.[Footnote
4] Although the exact number is unknown, many individuals with diabetes
have health coverage not subject to state insurance regulation because
their employers self-fund their health plans; that is, the employers
pay the cost of health benefits directly, instead of purchasing
insurance. In addition, the Federal Employees Health Benefits Program
(FEHBP)--through which the federal Office of Personnel Management (OPM)
contracts with private health insurance carriers to offer health
coverage to federal employees, retirees, and their dependents[Footnote
5]--is not subject to state insurance requirements.[Footnote 6]
In this context, we examined the following three questions:
1. To what extent do state laws or regulations require health insurance
policies to cover diabetes services and supplies?
2. To what extent does health coverage not subject to state insurance
requirements--specifically, coverage provided by the largest health
plans participating in FEHBP and the largest private self-funded health
plans--include diabetes services and supplies?
3. To what extent do individuals with diabetes, including those with
health coverage and those without, receive diabetes services and
supplies?
To answer these questions, we obtained information from federal health
agencies and national organizations concerned with diabetes patient
care, and we identified 10 services and nine supplies that individuals
with diabetes may need.[Footnote 7] To examine the extent to which
states require health insurance policies to cover diabetes services and
supplies, we reviewed state laws and regulations related to diabetes
coverage.[Footnote 8] To assess the extent to which health coverage not
subject to state requirements--such as coverage provided by the largest
plans participating in FEHBP and by selected large employers' self-
funded plans--includes diabetes services and supplies, we contacted the
three largest national plans participating in FEHBP--Blue Cross and
Blue Shield, Mail Handlers, and Government Employees Hospital
Association, Inc.[Footnote 9]--as well as a random sample of 15 of the
largest 50 Fortune 500 companies regarding their plans' coverage of
diabetes services and supplies in 2004.[Footnote 10] We received
responses from all three FEHBP plans, which covered approximately 5.3
million people in 2003, and from 13 of 15 of the employers we
contacted, which together employed about 2.4 million people in
2003.[Footnote 11] To collect information on the extent to which
individuals with diabetes with and without health coverage receive
diabetes services and supplies, we analyzed data provided by CDC from
an annual national survey of individuals ages 18 and older known as the
Behavioral Risk Factor Surveillance System (BRFSS). This survey,
conducted by the states, consists of self-reported data gathered from
telephone interviews.[Footnote 12] We used data collected during 2003,
the most recent year available. We also obtained data from another CDC
survey known as the National Health and Nutrition Examination Survey
(NHANES). Unlike BRFSS, this survey combines an in-home interview with
a physical examination to assess the health of a nationally
representative sample of the noninstitutionalized U.S. population,
including a representative sample of individuals with
diabetes.[Footnote 13] We used data collected by this survey from 1999
through 2002 for individuals ages 18 and older. To assess data
reliability, we reviewed CDC documentation of its data collection and
discussed the data and their appropriate use with CDC officials. We
determined that the data were sufficiently reliable for our purposes.
We conducted our work according to generally accepted government
auditing standards from July 2004 through January 2005. Additional
details about our scope and methodology appear in appendix I.
Results in Brief:
In 2004, 47 states had laws or regulations related to coverage of
diabetes services or supplies, although the specific coverage
requirements varied by state. States most often required coverage of
two diabetes services: diabetes education and medical nutrition
therapy. Forty-five states required diabetes education, and 27 required
medical nutrition therapy. National organizations concerned with
diabetes patient care have worked with states to develop laws and
regulations addressing these services in particular because other
services, such as eye and foot exams, were thought to be covered by
most health plans as general medical services. In addition, 47 states
had coverage requirements related to diabetes supplies, although some
states were more specific than others about which supplies must be
covered.
The plans we contacted that provide coverage not subject to state
insurance requirements--specifically, the 3 largest health plans
participating in FEHBP and 13 of the largest employers' self-funded
plans--covered most of the diabetes services and supplies we reviewed,
in most cases without limits on the coverage. Each of the 3 FEHBP plans
and the 13 self-funded plans we contacted covered at least 7 of the 10
diabetes services, such as an annual blood glucose test, cholesterol
and blood pressure monitoring, and influenza vaccinations. Services
covered less often included diabetes education, medical nutrition
therapy, and smoking cessation therapy. All 16 plans also covered at
least five of the nine diabetes supplies we reviewed, including insulin
and insulin-administering supplies; most of these plans also covered
blood glucose monitors, glucose control solutions, alcohol swabs, and
therapeutic shoes.
Data from CDC's 2003 nationwide survey showed that a majority of
individuals with diabetes ages 18 and older reported receiving at least
one diabetes service within the past 12 months; a much smaller
proportion, however, reported receiving five services that experts
recommend that individuals with diabetes receive at least once a year.
Nationwide, an estimated 88 percent of individuals with diabetes had
received a test for blood glucose within the past 12 months, whereas an
estimated 33 percent had received five services: blood glucose and
cholesterol tests, eye and foot exams, and an influenza vaccination.
Receipt of services and supplies among individuals with diabetes varied
by service, state, and whether an individual had health coverage. For
example, an estimated 71 percent of individuals with diabetes who had
health coverage at the time of the survey had received eye exams,
compared with 46 percent of those who lacked health coverage. Other CDC
survey data indicate that many individuals with diabetes do not have
adequate control of diabetes-related conditions that may increase their
risk of complications.
We provided a draft of this report to CDC for comment. The agency
provided us with technical comments, which we incorporated into the
report as appropriate.
Background:
Diabetes, a chronic disease, was the sixth leading cause of death in
the United States in 2000, contributing to the loss of more than
200,000 lives, according to CDC. Type 1 diabetes, in which the body
fails to produce insulin, is usually diagnosed in children and young
adults. Type 2 diabetes, in which the body fails to use insulin
properly, is associated with aging, a family history of diabetes,
physical inactivity, and obesity and accounts for 90 to 95 percent of
all diabetes cases. Although type 2 diabetes occurs most often among
adults, it is increasingly being diagnosed in children and
adolescents.[Footnote 14] One study found that, on average in 2002,
individuals with diabetes incurred about $13,243 in health care
expenditures, compared with about $2,560 in expenditures for
individuals without diabetes.[Footnote 15] These estimates include
costs attributed to complications of diabetes, such as cardiovascular
disease, neurological symptoms, and kidney disease.
Federal health agencies and national organizations concerned with
diabetes patient care have identified a number of services and supplies
that individuals with diabetes often need to help manage their disease.
Table 1 lists services considered important for diabetes patient care
by the American Association of Diabetes Educators; the American
Dietetic Association; and the National Diabetes Quality Improvement
Alliance (Alliance), a consortium of 13 private-sector organizations
and government agencies, including the American Diabetes Association
(ADA), CDC, and the Centers for Medicare & Medicaid Services.[Footnote
16]
Table 1: Services for Managing Diabetes:
Service: Blood glucose (A1c) management[A];
Importance for patient care: Regular, frequent monitoring of glucose in
the blood (as HbA1c, hemoglobin A1c, or glycosylated hemoglobin)
reduces the risk of complications such as nerve damage, kidney disease,
and vision disorders.
Service: Lipid (cholesterol) management;
Importance for patient care: Individuals with diabetes are at increased
risk of coronary heart disease. Lowering serum cholesterol levels can
reduce this risk.
Service: Urine protein screening for kidney disease;
Importance for patient care: Diabetes is the leading cause of end-stage
renal (kidney) disease. The earliest clinical evidence of kidney
disease is the appearance of low but abnormal levels of a protein
(albumin) in the urine. Early detection and treatment of this condition
may prevent or slow the progression of diabetic kidney disease.
Service: Eye exam for eye disease;
Importance for patient care: Individuals with diabetes are at increased
risk of blindness caused by retinopathy, or diseases of the retina, the
light-sensitive tissue at the back of the eye that is needed for
vision. The prevalence of retinopathy is strongly related to the
duration of diabetes, but treatment can prevent or delay onset.
Service: Foot exam to detect problems with circulation and sensation;
Importance for patient care: Individuals with diabetes are at increased
risk of foot ulcers and amputations. Annual foot exams and management
of risk factors can prevent or delay poor outcomes.
Service: Influenza immunization;
Importance for patient care: Individuals with diabetes are considered
to be at increased risk of complications, hospitalization, and death
from influenza, as well as of secondary infections, such as pneumonia,
resulting from influenza.
Service: Blood pressure management;
Importance for patient care: Controlling blood pressure in patients
with diabetes reduces diabetes complications, diabetes-related deaths,
strokes, heart failure, and other complications.
Service: Diabetes education;
Importance for patient care: Diabetes education teaches individuals to
manage their disease through activities including exercise and blood
glucose monitoring.
Service: Medical nutrition therapy;
Importance for patient care: Medical nutrition therapy is a specific
nutrition service and procedure used to treat illnesses or health
conditions. It involves an in-depth nutrition assessment, changes in
diet as appropriate, and follow-up monitoring and evaluation.
Service: Smoking cessation therapy: counseling or drugs;
Importance for patient care: Individuals with diabetes who smoke are
more likely to suffer nerve damage and kidney disease. Smoking also
damages and constricts blood vessels, which can worsen foot ulcers and
leg infections. In addition, smoking increases blood pressure and blood
glucose.
Sources: American Association of Diabetes Educators, American Diabetes
Association, American Dietetic Association, and National Diabetes
Quality Improvement Alliance.
Note: In addition to the services listed in this table, the Alliance
also recommends aspirin therapy to help prevent stroke, heart attack,
and other cardiovascular problems in adults with diabetes. Because
aspirin is an over-the-counter medication not typically covered by
health plans, we excluded aspirin therapy from our review.
[A] A1c tests differ from traditional home glucose monitoring, which
usually involves pricking a finger, putting a drop of blood on a test
strip, and placing the strip into a meter that displays the level of
glucose in the blood. A1c tests are done in a health care provider's
office and measure the average level of glucose in the blood over the
preceding 3 months. For some patients, daily (or sometimes hourly) self-
testing for glucose level is recommended to provide a short-term
glucose assessment, but experts recommend at least one A1c test
annually for all diabetes patients to assess a patient's general
glucose level.
[End of table]
In addition to such services, according to federal agencies and
organizations concerned with diabetes patient care, individuals with
diabetes often need certain supplies to manage their disease. Needed
supplies may include blood glucose monitors, glucose control solutions
(used to check the accuracy of testing equipment and test strips), test
strips, lancets and lancet devices (used to prick the skin for a blood
sample to self-test blood glucose levels), insulin (when necessary),
insulin pumps (to administer insulin), disposable needles and syringes
(also to administer insulin), alcohol swabs, and therapeutic shoes (for
individuals with severe diabetic foot disease).
Health coverage may be provided through the purchase of insurance
policies that are subject to state laws and regulations or through
means other than insurance. Health coverage provided through the
purchase of insurance in a given state, whether purchased by
individuals or by employers, is subject to insurance requirements in
that state, including requirements to cover specified illnesses,
services, or supplies.[Footnote 17] For example, states often require
coverage of cancer-screening services such as mammography or tests for
colorectal cancer.[Footnote 18] These state requirements are in
addition to coverage requirements established by federal law. In 2001,
two-thirds of Americans younger than 65 (the age at which people
generally become eligible for Medicare),[Footnote 19] received health
coverage through their own employer or that of a family member. Large
private employers often self-fund their health plans,[Footnote 20] and
coverage provided by these plans is not subject to state insurance
regulation, although it is generally subject to federal
requirements.[Footnote 21] Health coverage provided by the federal
government is also not subject to state insurance regulation. For
FEHBP, OPM is responsible for contracting with private health insurance
carriers to offer health benefit plans to federal employees. By federal
law, the terms of any FEHBP contract negotiated by OPM that relate to
coverage or benefits preempt any inconsistent state or local law or
regulation. OPM routinely preempts state requirements to ensure a
consistent set of benefits among nationwide FEHBP plans, according to
an OPM official.[Footnote 22]
Most States Require Insurance Policies to Cover Diabetes Services and
Supplies, Although Specific Requirements Vary:
In 2004, 47 states had laws or regulations related to coverage of
diabetes services or supplies, although specific requirements varied by
state (see fig. 1 and app. II). Forty-five states required insurance
policies to cover specific services or supplies for diabetes.[Footnote
23] Two more states, Mississippi and Missouri, required "mandated
offerings"; that is, these states required insurance policies to
provide coverage for diabetes at the option of purchasers. Some states'
requirements applied only in narrow circumstances. For example, Arizona
and Wisconsin required coverage of diabetes supplies only when a health
insurance policy covered the treatment of diabetes.[Footnote 24] The
services most frequently specified in state requirements were diabetes
education and medical nutrition therapy: 45 states required that
insurance policies cover diabetes education, and 27 states required
coverage of medical nutrition therapy.[Footnote 25] State requirements
may have focused more often on these two services in part because
national organizations concerned with diabetes patient care--including
ADA, the American Dietetic Association, and the American Association of
Diabetes Educators--have supported "model" legislation centered on
these two services. According to ADA and the American Dietetic
Association, the organizations focused on these two services in
particular because others, such as eye and foot exams, were thought to
be covered by most policies as general medical services. The model
legislation also includes coverage of "diabetes equipment and
supplies," and 47 states required such coverage. Twenty-eight states
identified which supplies must be covered, although their specific
requirements varied.
Figure 1: Number of States Requiring Coverage of Diabetes Services and
Supplies, 2004:
[See PDF for image]
[End of figure]
Some states had specific requirements regarding the coverage of certain
services, such as diabetes education. Forty-two states specified at
least some criteria for the training or education that health care
professionals must have to provide diabetes education. These criteria
varied widely from state to state. To provide diabetes education in
Louisiana, for example, health professionals must have demonstrated
expertise in diabetes and must have completed an educational program in
compliance with the National Standards for Diabetes Self-Management
Education established by ADA. In contrast, several states required
educators to be licensed professionals with expertise in diabetes but
did not define the term expertise. Eight states referred to ADA's
national standards in setting their requirements for diabetes education
programs. Some of these states required programs to be consistent with
these standards, while others mentioned them as an example of
acceptable standards.
Among the 47 states whose laws or regulations required coverage of
diabetes supplies, specific coverage requirements varied. For example,
19 states did not specify which supplies must be covered;
instead, these states typically required coverage of all medically
necessary equipment and supplies prescribed by a physician. The
remaining 28 states specified covered supplies, either in laws or
regulations, but the number of supplies varied among the states. For
example, Michigan had requirements related to insulin, blood glucose
monitors, test strips, lancets, lancet devices, syringes, and insulin
pumps. In contrast, Mississippi required coverage of equipment and
supplies, including supplies used in connection with blood glucose
monitoring and insulin administration, but did not specify which
supplies. Some states that listed covered supplies also prescribed
procedures for adding new supplies to the list. For example, in New
Jersey, the Commissioner for Insurance, in consultation with the
Commissioner of Health, may update the list of supplies.
While nearly all states have required some coverage of diabetes
services or supplies in the insurance policies they regulate, some
states have authorized a class of health insurance policies that are
not bound by many of the state coverage requirements, which may include
those for coverage of diabetes services and supplies. Known as
"flexible health benefit" or "limited-benefit" policies, and typically
marketed to small employers or individuals, such policies may, through
lower premiums, reduce the cost of coverage. At least two states,
Louisiana and Arkansas, have authorized limited-benefit policies that
are not bound by requirements related to diabetes services and
supplies.[Footnote 26] Louisiana has authorized such policies for
individuals not otherwise able to obtain health coverage and for small
employers (3-35 employees), and Arkansas has authorized them for all
groups, regardless of size. ADA is concerned that limited-benefit
policies may not provide sufficient coverage of the services and
supplies that individuals with diabetes need to manage their condition.
Selected Health Plans Providing Coverage Not Subject to State
Regulation Cover Most but Not All Diabetes Services and Supplies:
The 3 largest plans participating in FEHBP--Blue Cross and Blue Shield,
Mail Handlers, and Government Employees Hospital Association, Inc.--and
the 13 large-employer self-funded plans we contacted covered most of
the diabetes services and supplies we reviewed. All 16 plans covered at
least 7 of the 10 diabetes services, as well as at least five of nine
diabetes supplies. Few of the plans we contacted placed limits on
coverage for diabetes services and supplies.[Footnote 27]
Three Largest FEHBP Plans Cover Most Diabetes Services and Supplies:
The three largest FEHBP plans covered at least 8 of the 10 diabetes
services we reviewed (see table 2). Both diabetes education and medical
nutrition therapy were covered by two of the three plans, although one
plan placed conditions on these services: diabetes education was
covered when provided at a hospital and medical nutrition therapy when
provided by a physician. The three plans stated that coverage
requirements for diabetes services and supplies applied only in cases
of medical necessity. The plans generally did not, however, set
monetary limits on their coverage for diabetes services. One exception
was smoking cessation therapy, for which one plan set $100 lifetime
limits per enrollee for both counseling and drug therapy. Another plan
set $100 lifetime limits per enrollee for smoking cessation counseling.
Table 2: Diabetes Services Covered by the Three Largest FEHBP Plans,
2004:
Service: Blood glucose test;
Blue Cross and Blue Shield: X;
Mail Handlers: Yes;
Government Employees Hospital Association, Inc.: Yes.
Service: Lipid profile;
Blue Cross and Blue Shield: Yes;
Mail Handlers: Yes;
Government Employees Hospital Association, Inc.: Yes.
Service: Urine protein screening;
Blue Cross and Blue Shield: Yes;
Mail Handlers: Yes;
Government Employees Hospital Association, Inc.: Yes.
Service: Eye exam;
Blue Cross and Blue Shield: Yes;
Mail Handlers: Yes;
Government Employees Hospital Association, Inc.: Yes.
Service: Foot exam;
Blue Cross and Blue Shield: Yes;
Mail Handlers: Yes;
Government Employees Hospital Association, Inc.: Yes.
Service: Influenza vaccination;
Blue Cross and Blue Shield: Yes;
Mail Handlers: Yes;
Government Employees Hospital Association, Inc.: Yes.
Service: Blood pressure management;
Blue Cross and Blue Shield: Yes;
Mail Handlers: Yes;
Government Employees Hospital Association, Inc.: Yes.
Service: Smoking cessation therapy;
Blue Cross and Blue Shield: Yes;
Mail Handlers: Yes;
Government Employees Hospital Association, Inc.: Yes.
Service: Diabetes education;
Blue Cross and Blue Shield: Yes;
Mail Handlers: No;
Government Employees Hospital Association, Inc.: Yes.
Service: Medical nutrition therapy;
Blue Cross and Blue Shield: Yes[A];
Mail Handlers: No;
Government Employees Hospital Association, Inc.: Yes.
Source: GAO analysis of data from the three largest FEHBP plans.
[A] Covered for enrollees with a diagnosis of diabetes.
[End of table]
The three FEHBP plans all covered at least seven of nine diabetes
supplies, including blood glucose monitors, glucose control solutions,
test strips, lancets and lancet devices, insulin, insulin pumps, and
disposable needles and syringes. One plan did not cover alcohol swabs,
and two plans did not cover therapeutic shoes. One plan limited its
coverage of supplies; specifically, this plan set lifetime durable
medical equipment limits of $10,000 per person for specific supplies,
including blood glucose monitors and insulin pumps.
Large Employers' Self-Funded Health Plans Reviewed Cover Most Diabetes
Services and Supplies:
Each of the 13 large employers' self-funded health plans we reviewed
covered at least 7 of 10 diabetes services, specifically, blood
glucose, lipid, and urine tests; eye and foot exams; blood pressure
management, and influenza vaccinations. The remaining 3 services were
covered by at least 9 plans (see fig. 2). Among these plans, we found
limits on coverage only for smoking cessation therapy. One plan, for
example, had a lifetime maximum of three drug therapy treatments for
smoking cessation, and another plan had a maximum of two smoking-
cessation programs per lifetime for each enrollee for both counseling
and drug therapy.
In a few cases, the plans specified certain conditions for coverage.
For example, among the 11 plans offering coverage of diabetes
education, 4 did so only if an employee with diabetes was enrolled in
the plan's diabetes management program. Three of the 10 plans offering
coverage of medical nutrition therapy did so only as part of their
diabetes management program. Of the 9 plans covering smoking cessation
therapy, 5 restricted coverage to drug therapy and did not cover
smoking cessation counseling. Most of the self-funded plans stipulated
that diabetes services and supplies were covered only when medically
necessary.[Footnote 28] In addition, 7 plans required waiting periods
ranging from 30 days to 6 months after an employee was hired before
health coverage began. One plan did not cover preexisting conditions--
either an injury or illness--occurring during the 90 days before a
newly hired employee began the waiting period.
Figure 2: Diabetes Services Covered by 13 Large Employers' Self-Funded
Health Plans, 2004:
[See PDF for image]
[End of figure]
All 13 self-funded plans covered at least five of nine diabetes
supplies, including insulin, insulin pumps, disposable needles and
syringes, test strips, and lancets and lancet devices, and all but 1
covered blood glucose monitors (see fig. 3). Only 1 of the 13 plans
reported having limits on the quantity of supplies covered, covering
one blood glucose monitor per year. Two of the 13 plans reported
placing conditions on their coverage of supplies. For example, 1 plan
told us that it allowed up to a 90-day supply of items for each claim,
and another plan covered therapeutic shoes when prescribed by a
physician and purchased through an authorized supplier.
Figure 3: Diabetes Supplies Covered by 13 Large Employers' Self-Funded
Health Plans, 2004:
[See PDF for image]
[End of figure]
Nationwide, Receipt of Diabetes Services and Control of Related Health
Conditions Are Uneven:
Data from CDC's 2003 nationwide survey showed that individuals with
diabetes received some but not all diabetes services, and those who had
health coverage were more likely to have received services than those
who did not. The proportion of individuals with diabetes receiving
diabetes services varied widely by type of service and among states.
Another CDC survey, which included a physical examination of
participants, indicated that many individuals with diabetes did not
have their diabetes-related conditions adequately controlled.
Individuals with Diabetes Report Receiving Many but Not All Services:
National data show that individuals with diabetes ages 18 and older
receive many but not all diabetes services. In a nationwide telephone
survey conducted in 2003, the majority of individuals with diabetes
reported receiving at least one of six identified diabetes services for
which national data were available.[Footnote 29] Substantially fewer
individuals reported receiving within the past 12 months the five
services recommended that individuals with diabetes receive at least
once a year. Although the receipt of services varied by service, half
or more of the individuals with diabetes reported receiving each given
service. For example, an estimated 88 percent had received a test for
blood glucose within the past 12 months, and an estimated 52 percent
had received diabetes education. A much smaller proportion, 33 percent,
had received the five services recommended that individuals with
diabetes receive at least once a year--specifically, a blood glucose
test, a cholesterol test, an eye exam, a foot exam, and an influenza
vaccination (see fig. 4).[Footnote 30]
Figure 4: Estimated Nationwide Percentage of Individuals Ages 18 and
Older with Diabetes Who Reported Receiving Diabetes Services, 2003:
[See PDF for image]
Notes: These nationwide estimates were constructed from available state
data. Data represent the estimated percentage of individuals ages 18
and older nationwide who reported receiving a service within the past
12 months, except for diabetes education, for which respondents were
asked if they had ever received the service (specifically, participants
were asked if they had ever taken a course on how to manage their
diabetes). Data for "Five services" represent the estimated percentage
of individuals who reported receiving all of five services recommended
that individuals with diabetes receive at least once a year: a blood
glucose test, a cholesterol test, a foot exam for sores or irritations,
an eye exam in which the pupils were dilated, and an influenza
vaccination.
[End of figure]
CDC's survey also indicated that an estimated 82 percent of individuals
with diabetes were taking insulin or diabetes medication to control
their blood glucose.[Footnote 31] Otherwise, use of diabetes supplies
was not captured in CDC's survey.
Individuals with Diabetes Who Have Health Coverage More Likely to
Receive Services Than Those Who Lack Coverage:
According to CDC's 2003 survey, in comparison with individuals with
diabetes who lacked health coverage, a larger proportion who had health
coverage reported receiving one or more services. For example, an
estimated 90 percent of individuals with diabetes who had health
coverage at the time of the survey had received a blood glucose test,
compared with 71 percent of those who reported not having such coverage
(see fig. 5). Moreover, the estimated proportion of individuals with
diabetes who received all of the five diabetes services was more than
twice as high for those who had coverage than for those who did not.
For example, although an estimated 35 percent of those with health
coverage had received a blood glucose test, a cholesterol test, eye
exam, foot exam, and influenza vaccination, just 14 percent of those
without health coverage received the same set of services.
Figure 5: Estimated Nationwide Percentage of Individuals Ages 18 and
Older with Diabetes, With and Without Health Coverage, Who Reported
Receiving Diabetes Services, 2003:
[See PDF for image]
Notes: These nationwide estimates were constructed from available state
data. Data represent the estimated percentage of individuals ages 18
and older nationwide who reported receiving a service within the past
12 months, except for diabetes education, for which respondents were
asked if they had ever received the service (specifically, participants
were asked if they had ever taken a course on how to manage their
diabetes). Data for "Five services" represent the estimated percentage
of individuals who reported receiving all of five services recommended
that individuals with diabetes receive at least once a year: a blood
glucose test, a cholesterol test, a foot exam for sores or irritations,
an eye exam in which the pupils were dilated, and an influenza
vaccination.
[End of figure]
Receipt of Diabetes Services Varies Widely among States:
CDC's 2003 survey showed substantial variation among states in the
receipt of diabetes services. Depending on the service, the estimated
state-by-state percentages of individuals with diabetes who reported
receiving services varied widely. For example, the estimated state-by-
state percentages of individuals with diabetes who reported receiving
an eye exam ranged from 55 to 84 percent (see table 3). Despite this
state-by-state variation, the same services were generally the most
received across all states. In most states, for example, more
individuals received blood glucose and cholesterol tests than received
foot exams or diabetes education.
Table 3: Range among States in Estimates of Diabetes Services Received
by Individuals with Diabetes, 2003:
Service: Blood glucose (A1c) test;
State percentages[A]: 74 to 97;
Number of states[B]: 46.
Service: Cholesterol test;
State percentages[A]: 79 to 92;
Number of states[B]: 51.
Service: Foot exam;
State percentages[A]: 59 to 82;
Number of states[B]: 45.
Service: Eye exam;
State percentages[A]: 55 to 84;
Number of states[B]: 44.
Service: Influenza vaccination;
State percentages[A]: 46 to 75;
Number of states[B]: 49.
Service: Diabetes education (ever received);
State percentages[A]: 37 to 67;
Number of states[B]: 45.
Service: Five services[C];
State percentages[A]: 23 to 48;
Number of states[B]: 44.
Source: CDC's BRFSS.
[A] State percentages reflect the estimated proportion of individuals
ages 18 and older with diabetes in a given state who reported receiving
a service within the past 12 months, except for diabetes education.
[B] Numbers of states vary because not all states provided data for all
diabetes services in 2003. Because the sample sizes of individuals with
diabetes reporting receipt of each service for each state were
relatively small, the confidence intervals were relatively large. Any
state whose 95 percent confidence interval for any estimate exceeded
plus or minus 10 percentage points was excluded from this analysis.
[C] "Five services" represents the estimated percentage of individuals
who reported receiving the five services recommended that individuals
with diabetes receive at least once a year: a blood glucose test, a
cholesterol test, a foot exam for sores or irritations, an eye exam in
which the pupils were dilated, and an influenza vaccination.
[End of table]
Many Individuals with Diabetes Do Not Have Adequate Control of Related
Conditions That May Increase Their Risk of Complications:
For 1999-2002, data from CDC's NHANES--a nationally representative
survey that involves a physical examination to assess each
participant's health--indicated that many individuals with diabetes
ages 18 and older did not have adequate control of related conditions
that could lead to health complications.[Footnote 32] Experts say that
controlling blood glucose and cholesterol levels lowers the risk of
nerve damage, vision disorders, and cardiovascular disease; detecting
renal disease early decreases the risk of kidney failure.[Footnote 33]
Yet data from CDC's NHANES showed that about 19 percent of examined
participants with diabetes had poor control of their blood
glucose,[Footnote 34] and about half of them had cholesterol levels
putting them at increased risk for cardiovascular disease. In addition,
about 40 percent were at increased risk of renal disease, as evidenced
by a positive test for abnormal levels of a protein in their
urine.[Footnote 35] The data also showed that about 38 percent of
individuals with diabetes who did not have health coverage had glucose
levels indicative of poor control, compared with about 16 percent of
those who had health coverage.
Agency Comments:
We provided a draft of this report to CDC for comment. The agency
provided us with technical comments, which we incorporated into the
report as appropriate.
As agreed with your offices, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days
after its issue date. At that time, we will send copies to interested
congressional committees and members and make copies available to
others upon request. In addition, the report will be available at no
charge on the GAO Web site at http://www.gao.gov.
If you or your staffs have any questions about this report, please
contact me at (202) 512-7118. Another contact and key contributors to
this report are listed in appendix III.
Signed by:
Kathryn G. Allen:
Director, Health Care--Medicaid and Private Health Insurance Issues:
[End of section]
Appendix I: Scope and Methodology:
To assess health care coverage and receipt of diabetes services and
supplies, we obtained information from federal health agencies and
national organizations concerned with diabetes patient care and
identified 10 services and nine supplies that individuals with diabetes
often need. To determine the extent to which states require coverage of
diabetes services and supplies for the health insurance policies they
regulate, we examined state laws and regulations from September 2004
through December 2004 related to diabetes and the extent to which they
required coverage of specific services and supplies. We also reviewed
information prepared by the American Diabetes Association (ADA) and the
American Dietetic Association and interviewed officials there, as well
as from states and the National Conference of State Legislatures. In
addition, we reviewed state requirements for limited-benefit policies-
-which are not required to comply with coverage requirements usually
applicable to health insurance--in Louisiana, Arkansas, and Colorado.
To examine the extent to which the largest plans participating in the
Federal Employees Health Benefits Program (FEHBP) and the largest self-
funded employer plans cover diabetes services and supplies, we obtained
information from the three largest national FEHBP plans--Blue Cross and
Blue Shield, Mail Handlers, and Government Employees Hospital
Association, Inc.--which together covered approximately 5.3 million
people in 2003, or about 65 percent of employees, retirees, and their
dependents covered by FEHBP plans. We also contacted a random sample of
15 of the 50 largest Fortune 500 companies, ranked by the number of
employees, regarding their plans' coverage of diabetes services and
supplies in 2004 and received responses from 13 of them. Together these
13 large companies, which had self-funded health plans, employed about
2.4 million people in 2003. Because employers may offer their employees
more than one health plan option, we asked employers to provide
coverage information related to the health plan that had the largest
enrollment. We relied on the information as reported by officials of
the health plans reviewed and did not independently verify their
responses. Because of our sampling approach, we cannot generalize our
findings to all FEHBP plans or to all large employers. Although we
received responses from most (16 of 18) of the FEHBP plans and
employers we contacted, our results may still reflect some selection
bias, in that employers offering more benefits might have been more
likely to respond than those offering fewer benefits.
To assess information on the extent to which individuals with diabetes
receive diabetes services and use supplies, we analyzed data for
individuals ages 18 and older provided by the Centers for Disease
Control and Prevention (CDC) from two nationwide surveys: the
Behavioral Risk Factor Surveillance System (BRFSS) for 2003 and the
National Health and Nutrition Examination Survey (NHANES) for 1999-
2002:
* BRFSS is a nationwide telephone survey conducted every year by state
health departments, with technical and methodological assistance
provided by CDC. A "cross-sectional" or point-in-time survey, BRFSS
samples the civilian noninstitutionalized population of adults ages 18
and older in the United States, including the 50 states and the
District of Columbia;[Footnote 36] all data from BRFSS are self-
reported. The survey's purpose, methods, and data analyses are
available at http://www.cdc.gov/brfss. We used data from CDC gathered
during 2003 about services individuals with diabetes reported receiving
within the 12 months preceding the survey, which represented the most
recent information available. BRFSS 2003 included a representative
sample of 19,162 participants with diabetes. In addition to questions
from the core sections of the survey, we used questions from a diabetes-
specific section, which included data from 46 states in 2003, to
collect data on disease management practices from respondents with
diabetes.
* NHANES is a nationally representative survey, whose data are
collected every year and released every 2 years by CDC, that samples
the civilian noninstitutionalized U.S. population. It is a two-part
survey, consisting of an in-home interview plus a health examination in
a mobile examination center. Its purpose, methods, and data analyses
are available at http://www.cdc.gov/nchs/nhanes.htm. We used NHANES
data from 1999-2002--the most recent information available--for adults
ages 18 and older, which included a representative sample of 904
participants with diabetes. We relied on NHANES results from the
physical examinations, which included laboratory tests, for specific
test values for individuals who had reported a prior diagnosis of
diabetes, including tests for blood glucose, cholesterol, and kidney
disease.
We examined data provided to us by CDC from each survey separately.
When possible, the data were stratified by health coverage status
(respondents who reported having health coverage and those who reported
not having it).[Footnote 37] For both surveys, we used data only from
respondents who reported receiving a diagnosis of diabetes before the
survey period. Most of CDC's estimates from BRFSS were stratified by
state, although we could not develop state-level estimates by health
coverage; NHANES estimates were limited to the national level. We
analyzed a total of 10 indicators for diabetes services and supplies
from both surveys (see table 4).
Table 4: Indicators of Services and Supplies for Managing Diabetes:
Diabetes indicator[A]: Percentage of patients who report receiving one
or more A1c tests;
Data source: BRFSS;
Population: National and state.
Diabetes indicator[A]: Percentage of patients with a measured A1c test
value >9.0%;
Data source: NHANES;
Population: National.
Diabetes indicator[A]: Percentage of patients who report receiving at
least one cholesterol test;
Data source: BRFSS;
Population: National and state.
Diabetes indicator[A]: Percentage of patients with a measured total
cholesterol value 200 mg/dl;
Data source: NHANES;
Population: National.
Diabetes indicator[A]: Percentage of patients who report receiving a
dilated-eye exam;
Data source: BRFSS;
Population: National and state.
Diabetes indicator[A]: Percentage of patients who report receiving at
least one foot exam for sores or irritations;
Data source: BRFSS;
Population: National and state.
Diabetes indicator[A]: Percentage of patients who report receiving an
influenza immunization[B];
Data source: BRFSS;
Population: National and state.
Diabetes indicator[A]: Percentage of patients who report ever taking a
diabetes self-management course;
Data source: BRFSS;
Population: National and state.
Diabetes indicator[A]: Percentage of patients who report currently
taking insulin or diabetes medication;
Data source: BRFSS;
Population: National and state.
Diabetes indicator[A]: Percentage of patients with a negative test for
nephropathy (kidney disease)[C];
Data source: NHANES;
Population: National.
Source: CDC.
[A] Unless otherwise noted, we used data from BRFSS about respondents'
receipt of diabetes services within the past 12 months. NHANES data
came from 1999-2002.
[B] The BRFSS question asks participants if they have received a "flu
shot," thus potentially excluding respondents who may have received an
intranasal immunization for influenza.
[C] A negative test for nephropathy is defined as a ratio of urinary
albumin to urinary creatinine of
