States seek enhanced DM for Medicaid patients

MEDICAID ENROLLEES who suffer from expensive, chronic conditions tend to suffer from so many comorbidities and complicating social problems-such as homelessness and lack of transportation-that isolating a single disease state for intervention is ineffective. And states are beginning to recognize that.

Ask a commercial plan administrator about disease management, and you're likely to hear about chronic conditions such as asthma, diabetes and heart failure. Ask a Medicaid plan administrator about disease management, and chances are you'll hear a lot more about the people than the conditions.

"A person is more likely to think about testing her blood sugar if she knows where her next meal is coming from," says David Hunsaker, president of APS, Public Programs, part of Silver Springs, Md.-based APS Healthcare.

APS's approach, which incorporates elements of case management, population management and community outreach, is characteristic of disease management programs in the Medicaid arena.

"It's not like there's an official playbook here or an official taxonomy," says Stephen Somers, president of the Center for Health Care Strategies. "One man's disease management may not be another's. But the states are recognizing that their Medicaid populations are more complex than the typical [commercial] disease management program is equipped to deal with. They're looking for enhanced disease management or comprehensive care management. They're taking outreach into the community with targeted subsets."

Given the expansive nature of the problem, solutions tend to be multifaceted. "Success in this field depends on doing a lot of things well," Hunsaker says. It may mean working with a faith-based organization or the local Meals on Wheels provider to reduce the amount of sodium in the food they prepare. It may mean posting nursing staff in community health centers to test patients' blood sugar while they are in the waiting room to ensure problems are detected and addressed before they leave or posting staff at the ER discharge desk to help Medicaid recipients find a medical home.

COMMON SENSE

At AmeriHealth Mercy Health Plan, a Medicaid plan in Pennsylvania, an intervention as simple as phoning asthmatics during a heat wave to make sure they had access to air conditioning helped prevent an uptick in visits to the ER, notes Anne Morrissey, president of Pennsylvania Managed Care, which manages AmeriHealth Mercy and Keystone Mercy.

Effectively addressing Medicaid populations means understanding the basic human hierarchy of needs. Although those needs aren't always health related, they can directly impact a person's ability or willingness to effect change. To that end, firms such as APS employ social workers to help people address critical life issues.

Effective disease management likewise calls for creative solutions, says Liz Reardon, managed care director for Vermont Health Access, the state's Medicaid agency. Understanding that a disproportionate number of Medicaid patients have mental illness and that some antipsychotic drugs can cause metabolic disorder and weight gain, the state piloted a program to put nurses in community mental health centers to help ensure the needs of diabetics were being met. After a year, diabetics involved in the program were four times more likely to seek routine care, and emergency room visits were down precipitously.

Today, there are more than 55 million Medicaid beneficiaries, Somers notes. That compares with 42 million just 10 years ago. Not surprisingly, there's been a corresponding increase in Medicaid costs: between 1995 and 2005 expenditures increased an average of 8.2% annually, according to The Lewin Group.