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  • Data Points #18: Use of and access to health care by Medicare beneficiaries with diabetes: impact of diabetes type and insulin use, 2007-2011

Data Points Publication Series



Research Report - Final – Jan. 29, 2014

Data Points #18: Use of and access to health care by Medicare beneficiaries with diabetes: impact of diabetes type and insulin use, 2007-2011

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Overview

In 2011, about 25 percent of the Medicare fee-for-service population had diabetes. Among Medicare beneficiaries with diabetes, approximately 14 percent had type 1, 85 percent had type 2 but did not use insulin, and less than 1 percent had type 2 diabetes and used insulin to manage their condition. Between 2007 and 2011, beneficiaries with type 2 diabetes who used insulin had the highest burden of comorbidity, hospitalization rates, and allowed payment, followed by those with type 1 diabetes. Most beneficiaries with diabetes had evaluation and management visits. Most also received needed preventive care, including HbA1c and LDL1 testing, and about half received an annual flu shot and eye exam. However, beneficiaries with type 2 diabetes using insulin had the lowest rates of receipt of preventive care. Most beneficiaries with diabetes visited both primary care and specialty providers. The number of providers with whom they had contact is high, indicating potential fragmentation in both primary and specialty care.

Diabetes is one of the most prevalent chronic health conditions in the United States. It is a major risk factor for cardiovascular disease and the leading cause of kidney failure, nontraumatic lower extremity amputations, and blindness among adults. The CDC estimates that 25.8 million people, or 8.3 percent of the United States population, had either diagnosed or undiagnosed diabetes in 2011. Currently, 11.3 percent of adults age 20 and over and 26.9 percent of adults age 65 and over have diabetes. Diabetes prevalence in the United States has doubled since 1995.3 In 2010 alone, about 1.9 million people age 20 and over were newly diagnosed with diabetes.

Diabetes is a condition in which the body does not produce or properly use insulin. Insulin is a hormone needed to convert sugars and starches into energy and to control blood sugar levels. Diabetes is divided into two categories: type 1 (also known as juvenile diabetes) and type 2 (also known as adult-onset diabetes). In general, people with type 1 diabetes do not produce sufficient insulin, while people with type 2 diabetes cannot properly process insulin (or are insulin resistant). Type 2 diabetes is often treated with oral medications or lifestyle changes such as improved diet and increased exercise, while type 1 diabetes typically requires use of insulin injections. However, patients with type 2 diabetes may also require insulin use to control their blood sugar levels.

Diabetes is a chronic condition that if untreated can have serious complications, such as glaucoma, neuropathy, and kidney failure. However, complications such as these can be prevented with proper treatment and maintenance. High-quality diabetes care is important to maintain the health and stability of people with diabetes. Care for diabetes is becoming even more important with the increasing prevalence of diabetes in the United States.

While important, care for diabetes can be resource and time intensive. Self-care for diabetes alone may take several hours per week. Care also may include taking multiple medicines to treat diabetes and conditions related to cardiovascular risk, hypertension, and dyslipidemia, along with other co-occurring chronic conditions such as depression. In addition, individuals with diabetes typically have multiple outpatient visits, and many have one or more hospitalizations, every year. Given all of these activities, the potential for fragmentation of care--and its association with acute or emergency utilization downstream--cannot be overlooked.

In this report, we describe the demographic characteristics of diabetes patients in the Medicare program and report hospitalization rates, rates of key preventive care use, and rates of visits to primary care physicians and certain specialists. We stratify all analyses by diabetes type--type 1, type 2 not using insulin, and type 2 using insulin. These categories provide useful insight about the types of patients for whom changes in diabetes management may be particularly beneficial. We would like to acknowledge the leadership of the DEcIDE Diabetes Consortium in establishing the scope and objectives of this report.

Conclusion

Our examination of health care use and access to providers by Medicare beneficiaries with diabetes points to several important findings. First, use of preventive and acute care varies dramatically between beneficiaries with type 1 diabetes, type 2 using insulin, and type 2 not using insulin.

We found that most beneficiaries with diabetes have contact with both primary care and specialty providers. However, the number of distinct providers with whom they have contact is sufficiently high that it calls the reality of care coordination into question.

If programs related to encouraging care coordination are to be considered a success, reducing the number of different providers seen is a logical place to focus. In addition, it may be helpful for evaluations to take into account the number of providers seen when assessing whether attempts at care coordination lead to better preventive care and reductions in acute care use.