Project Summary

This research project is in progress. PCORI will post the research findings on this page within 90 days after the results are final.

What is the research about?

People with diabetes often have other health problems such as high blood pressure, high cholesterol, or liver disease. Having more than one disease can make them all more difficult to manage. Patients often need multiple medicines to control their health problems. Healthcare providers may need to spend extra time planning care for these patients, working with their other doctors, and following up with patients online or by phone. Time spent planning and coordinating care outside of regular office visits for patients with several health problems is called chronic care management. Starting in 2015, providers can get paid for the time they spend managing Medicare patients’ care needs outside of normal office visits. Because this change is recent, researchers don’t know how hard or easy it is for providers to deliver these types of services. Researchers also don’t know whether paying providers for these types of services results in better health for patients with diabetes who also have other health problems.

Who can this research help?

This research can help policy makers and groups that pay for health care understand whether paying doctors for chronic care management services makes a difference in patients’ health.

What is the research team doing?

The research team is working with health clinics in Louisiana for this study. First, the research team wants to know what makes it harder or easier for healthcare providers to spend time on chronic care management. To find out, the research team is interviewing healthcare providers who work at clinics in the study and treat patients with diabetes. The research team is also interviewing patients who have diabetes and get care at one of the clinics. Additionally, they are interviewing clinic directors to learn more about how clinics spend extra time planning and managing care for patients with diabetes and other health problems.

The research team wants to find out if patients who have diabetes and other health problems have better health when their providers are paid for spending extra time to coordinate care outside of office visits. The team is reviewing medical records for these patients over a nine-year period. They are also sending surveys about overall health to patients in the study. The researchers are looking at

  • Whether patients have a change in blood sugar level
  • Whether clinics use the payment code for planning care
  • How often patients use healthcare services
  • Patients’ experience with chronic care management

Research methods at a glance

Design Elements Description
Design Mixed-methods study (qualitative study and observational cohort study)
  • Medicare-eligible patients (over 65 years old) with type 2 diabetes and at least one other chronic condition who receive care coordination services covered by the Chronic Care Management CPT code 99490
  • Patients ages 35–95 who registered at REACHnet and completed the PROMIS survey or PACIC+ survey (only for diabetes patients)
  • Medical directors from health systems in the Louisiana Clinical Data Research Network (LaCDRN)
  • Physicians and nurses who treat diabetes patients and work in clinic settings within LaCDRN partner health systems
Chronic care management (CCM) services: 20 minutes a month of non-face-to-face interaction between patients and qualified healthcare professionals such as physicians, advanced registered nurses, physician assistants, clinical nurse specialists, and certified nurse midwives; structured recording of patient health information, maintaining a comprehensive electronic care plan, managing transitions of care and other care management services, sharing patient health information in a timely fashion within and outside the practice, creating comprehensive care plans, and medical decision making

Primary: change in use of CMS care coordination reimbursement code, percentage of patients with hemoglobin A1c <7%

Secondary: blood pressure<140/90 mmHg; low-density lipoprotein cholesterol<100 mg/dL; documented smoking cessation counseling if a smoker; prescribed aspirin if there is existing vascular disease; diabetes complications; quality measures for diabetes, cardiovascular events, hospitalizations, emergency room visits, mortality, and patient-reported outcomes; qualitative interviews with physicians and patients who use CCM services

Timeframe 5 years before CCM reimbursement became available and 4 years after CCM reimbursement became available

Journal Citations

Related Journal Citations

Project Information

Lizheng Shi, MA, MS, PhD
Tulane University
Natural Experiments of the Impact of Population-Targeted Health Policies to Prevent Diabetes and Its Complications

Key Dates

January 2016
May 2022

Study Registration Information


Health Conditions Health Conditions These are the broad terms we use to categorize our funded research studies; specific diseases or conditions are included within the appropriate larger category. Note: not all of our funded projects focus on a single disease or condition; some touch on multiple diseases or conditions, research methods, or broader health system interventions. Such projects won’t be listed by a primary disease/condition and so won’t appear if you use this filter tool to find them. View Glossary
Populations Populations PCORI is interested in research that seeks to better understand how different clinical and health system options work for different people. These populations are frequently studied in our portfolio or identified as being of interest by our stakeholders. View Glossary
Intervention Strategy Intervention Strategies PCORI funds comparative clinical effectiveness research (CER) studies that compare two or more options or approaches to health care, or that compare different ways of delivering or receiving care. View Glossary
Research Priority Area
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Last updated: March 4, 2022