According to the Washington State Department of Social and Health Services in Olympia, studies have shown clearly that a relatively small number of beneficiaries with certain chronic illnesses account for a disproportionate share of Medicaid services. Because their care is complicated and demanding, those same patients tend to receive fragmented care involving multiple providers and multiple sites of care, including frequent hospitalizations.
Since Medicaid is having financial resource problems in most states, this type of patient population is a natural target for increased scrutiny. The department said it should be noted that the complexity-of-care and quality-of-care issues involved have persuaded many providers that a different system of managed care may be needed.
One reason for urgency in developing a better system of care is that the nation’s patient population is aging and the number of chronically ill beneficiaries in Medicaid can be expected to grow dramatically in the next few years. The department explained that the increased costs inherent in such a trend have very serious implications for the entire Medicaid spectrum.
Part of the challenge Washing-ton state has set for itself is to demonstrate that the kinds of disease management efforts that have been undertaken in the private sector to better coordinate health services and control costs will operate effectively with Medicaid. "There is ample reason to be hopeful that such practices will reduce unnecessary hospitalizations and emergency department visits, while encouraging regular office visits and thereby helping to reduce health care costs as well as improving health status," the department added.
Materials distributed by the agency include four examples of disease management success stories:
• A homeless dialysis patient lived in a temporary shelter that was closing. He ate his meals at a local mission and at churches. Because of past drug and alcohol problems as well as several incidents of time spent in jail, he had difficulty getting into permanent housing. Getting to dialysis regularly was a problem, in part, because of the unresolved housing issues. The care manager worked with the patient’s social worker and parole officer to find a housing situation with meals, and the patient now goes to dialysis regularly.
• A man struggled with a weight-loss plan and hypoglycemia, but his symptoms did not make sense to him. When he entered the state’s diabetes management program, he was frustrated. The program nurse learned that his blood sugars were being monitored every three months and he was not doing any home monitoring. As a result, he was having hypoglycemia when he followed his diet and couldn’t understand why. After discussions with the care nurse, he was able to begin daily self-glucose monitoring and tracking the results. He switched to a new physician who was very supportive of the program and encouraged him to stay in regular touch with the program nurse. After six months in the program, the client is adjusting his diet according to his blood sugar levels and says he feels better and understands why.
• A 50-year-old woman in the diabetes management program encountered neuropathy following back surgery and was ignoring her former physician’s advice to begin taking insulin. She was in pain and poor health and had concluded that it would be impossible for her to deal with her diabetes. Officials say her attitude began to change after just one visit with a program nurse. She said that contact inspired her to make positive changes — she started monitoring her blood sugar, controlling her diet, and exercising every day. She got a flu vaccination in the winter, checks her blood sugar twice daily, and hopes to stall the need for total dependence on her wheelchair. "It’s nice to know I have someone to help me," she has told state officials. "This program has turned my life around."
• A woman who had a morbid fear of needles would feel faint whenever she received a numbing shot before insertion of the larger dialysis needles. Over time, she grew more accustomed to the needles, but still dreaded that part of the procedure. The care manager talked with the clinical manager and proposed that the patient receive an anesthetic cream that numbs the skin. The nephrologist agreed, and today the patient no longer has needles anxiety because her dialysis has become pain-free.