CMs worked for more efficient authorization
ConnectiCare’s case managers in its DiabetiCare program joined forces with the HMO’s medical directors and local endocrinologists to improve the efficiency of the insulin pump authorization process.
"Gina [Dulak] and I live and breathe this disease, and we have learned a lot from case managing these patients. We were able to compile enough information so that the senior management team realized it was time to change the policy," says Ginette Levesque, RN, case manager for the DiabetiCare program in Farmington, CT.
She worked with her fellow case manager, Gina Dulak, RN, to get the policy changed so that the diabetic case managers are called on to help determine whether a patient is eligible for an insulin pump.
"We saw an opportunity here. We had a policy in place, and it was a reasonable policy, but by getting Gina and Ginnette involved, the decision-making process is more efficient. If you are evaluating whether or not someone is a good candidate for an insulin pump, it’s invaluable to have someone involved who knows the patient," says Jay Salvio, BSN, MBA, director of ConnectiCare’s Health Management department.
When the clinical review nurses get a request for an insulin pump, they get the case managers involved.
In some cases, the endocrinologist’s office calls Levesque or Dulak, and they are able to start compiling their information before the formal request for a pump is made.
Patients who need insulin pumps are getting two to five shots of insulin a day and still are not able to get their blood sugar under control. The blood sugar levels of most patients have been out of control for a long time and are facing serious complications. The HMO assumes that putting these patients on an insulin pump will be cost-effective by reducing complications, but it’s hard to quantify, Salvio adds.
"ConnectiCare has an interest in helping our members obtain tighter control over their blood sugar. The purchase of the pump is not so much in the interest of a short-term gain but a long-term gain because tighter insulation controls are shown to reduce complications of diabetes. We’re concerned about the members’ quality of life as well as the medical expenses," he says.