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On-Line Journal
Article
Case
Management Challenges in Population-Based Care
Revkah
Balingit, RN, CMC, September 6, 2001
Population-based care is one of the current buzzwords in the managed care arena. It is known by various names, including disease management and continuous health care. Whichever title is given to these programs, they all share similar traits. Population-based disease management programs can be defined as "integrated systems of interventions, measurements and refinements of health care delivery designed to optimize clinical and economic outcomes within a specific population."1 When asked, most people would verbalize a desire to decrease time spent being sick and to increase their overall quality of life. Given this, it would seem that implementing population-based disease management programs would be simple and straightforward, unfortunately, the reality is quite different.
While modern science continues to find new and better ways to treat disease, chronic diseases continue to consume health care dollars at an alarming rate. Population-based disease management programs share goals of health maintenance and prevention. While there is a potential to drastically cut high cost institutional care in favor of less expensive care in community settings, many barriers must first be navigated.
Under a disease management system, physicians would need to undergo a major shift in their clinical approach. Not surprising, there is much resistance on the part of many doctors to having someone else dictate how they must practice medicine. Practitioners have developed unique practice styles based on training and experience, and many feel threatened that their judgment is being questioned, particularly when direction is coming from non-physician sources, such as Nurse Case Managers. Additionally, our nation's traditional medical system has favored a fee for service type of reimbursement that promotes over-utilization and inefficiency. Even when physicians have a willingness to promote chronic disease management, many problems hamper their desire. Difficulties include lack of financial incentives with decreasing reimbursement from various payers resulting in the physician having to see more patients in less time, increasing regulatory standards, mountains of paperwork, and poorly trained support staff. As a result, fewer doctors are willing to take on the burden of patients with chronic illnesses into their practices.
The complexity of chronic illness requires a multidisciplinary approach, which includes a financial component. As a result, insurance companies, Managed Care Organizations, and other payer sources have stepped into the ring with strong financial reasons to promote disease management programs. They must find more effective ways to meet the health care needs of their members while ensuring fiscal viability. Population-based disease management programs would require changes in the current health care delivery system to make it more efficient and effective. Medicare and Medicaid programs add confusion with complicated regulatory standards, eligibility that can change monthly, and poor reimbursement. Payers also need to provide adequate support to the development of the actual program models and protocols, design financial incentive programs that will attract physicians, form partnerships with ancillary providers, provide adequate training to the professional staff administering the program, and be willing to invest in the information management systems that are critical to the overall success of the programs. Without this strong support base and commitment for the process to succeed, any program will be doomed to fail.
The most crucial aspect of success of any population-based disease management program involves the public; there are many reasons why patients are either unable or unwilling to participate in a disease management program. For many patients there is a lack of knowledge or understanding of the disease state and the outlined plan of care, which can be caused by a multitude of factors. There can be language and cultural barriers. It can be very difficult to locate a health care provider that speaks Farsi, Hmong, or Tagolog. It may be difficult to convince a Cambodian couple that their child's birth defect is not the result of the parents' past sins. Each area of the country has it's own unique set of problems. There is a "so-called urban health penalty, a confluence of such circumstances as poor nutrition, poverty and unemployment {with} deteriorating housing and violence".2 Urban overcrowding and poverty often lead to poor living conditions. It is not unusual to find two or more families living in a one or two bedroom apartment. In such confined spaces it can even become difficult to prevent someone from smoking around an asthmatic child. Transportation to and from health care providers can be difficult for those that must rely on inadequate public systems. The opposite also exists. Rural areas often lack modern facilities and practitioners, and public transportation is not available. Many can't afford even basic items such as aspirin, much less often-expensive medications prescribed by a physician. In many cultures, folk remedies are generally tried first, and Western medical care is only sought once a condition becomes advanced or critical. Age is a factor, and as our population grows older, there are increasing numbers of individuals living with chronic diseases. Social factors must be considered as well. A teenager with diabetes is tempted into noncompliance when her friends go out for pizza or ice cream. Of course, there are many individuals who engage in risky behavior and self-destructive activities such as smoking, IV drug use, and unprotected sex. When disease management is discussed, it is often in general and abstract terms. It must be remembered that it is not the disease that is actually being managed, but the individuals who happen to live with the disease.
As a Nurse Case Manager I have worked in varied health care settings and have experienced first hand how difficult it is to effectively manage my patients' health given their real-life situations and circumstances. While working as a Home Health Case Manager in rural northwest Colorado I visited patients that were so isolated, family members would transport me from the main road to the home via snowmobile. In 1995, I entered a home that had only an outside well as a water source, and found a patient who had recently undergone open-heart surgery at a facility in Denver, Colorado. After being discharged home to her trailer, she had developed an abscess in the graft site on her thigh. She required daily nursing visits to perform the complicated and involved wound care. The wound itself ran from her groin to just above the knee, and at its deepest it was open all to way down to the bone. It took an hour to remove the old dressing, irrigate the wound, and then repack it. The situation was complicated by the fact that the patient was diabetic. Despite all of our efforts, the wound would not heal. Through phone calls to the surgeon in Denver, it was determined that the patient would require reassessment and further treatment at a higher level of care. The patient was agreeable but we had to find a way to get her to Denver. There had just been a snowstorm, and the mountain pass to Denver was closed. Furthermore, the patient was a widow with no family in the area who could assist with transportation. Medicare and Medicaid would not cover this type of non-emergent ambulance transportation, and it was not appropriate to put the patient on a bus for the 5-hour trip. The nearest airport was 2 hours away, and she couldn't afford the $400 ticket, even if she could have tolerated the trip. The small family owned home care agency that I worked for finally made an arrangement with the ambulance company to transport this patient to her doctor in Denver, as soon as the mountain pass was reopened. The home care agency paid the bill, which exceeded $1000, without hope of reimbursement. It is not realistic to expect health care providers to absorb these types of costs and remain financially sound.
Working as a Utilization Management Coordinator/Case Manager for an HMO in California, I experienced first hand physician resistance to managed care. My department handled incoming preauthorization requests, and our responsibility as nurses was to evaluate each case clinically to assure that pre-established criteria were met. With frustrating regularity, requests would be faxed in from physicians' offices only partially completed, without adequate clinical documentation, asking for approval for a specific treatment or procedure. One particular case involved a request from an OB/GYN office seeking approval for a total abdominal hysterectomy. No clinical notes were included. As the nurse assigned to review this case I placed a call to the physician's office asking for chart notes to be faxed. When I read the notes I found that the patient had been having abnormal bleeding and painful menstruation. I consulted the nationally recognized published criteria, based on standards of clinical practice guidelines, to determine if this case met the criteria for medical necessity. The guidelines required documentation of additional clinical information. I needed to know whether the patient was anemic due to the abnormal bleeding and what non-surgical interventions had been attempted. I called back to the doctor's office and asked if any lab work had been done, such as a complete blood count, and also asked about what non surgical treatments had been tried, including medication. The office person placed me on hold and then the physician came on the line. I started to ask the same questions when the doctor became irate, actually yelling at me, saying things like, "Who do you think you are? I am a doctor!" and "You people, you insurance monsters, you can't tell me how to treat my patients!" All disease management programs require the use of nationally recognized guidelines and standards of care. Physicians must be willing to participate in the creation of these standards and then to practice within those guidelines.
As a Case Manager for a Managed Care Organization I was responsible for the creation of a disease management program for asthma. After careful research, a program was designed. Implementation was coordinated with a local home care agency, which acted as a partner in the venture, and provided actual in-home instruction to the patient. The program was met with a myriad of problems. Many of our patients and their families were reluctant to sign up for the program, giving various reasons. Patients and families complained when we couldn't provide printed materials in their language. Many of our patients had family members that were not in the country legally, and they were fearful that they might get reported, and that their loved ones would be deported. Furthermore, the home care agency that we had contracted with, could not always find the staff to make the visits at times when the patients could be home, or they would be unable to provide a staff member that spoke the patients' language. Physicians were reluctant to refer their patients to the program because they were then responsible to write orders and complete the required paperwork for the home care agency. When statistical reports were run, it was noted that emergency room visits and hospital admissions for asthma had not actually decreased. The patients that needed the program the most were not involved. The program was finally abandoned when the home care agency closed in 1999, following the changes in Medicare reimbursement policies. This ill-conceived disease management program was doomed on every front. The managed care organization's information management system was not refined enough to produce reliable demographic reports to allow identification of appropriate patients. The home care agency did not have adequate financial or staff resources, and the physicians did not demonstrate a commitment to the program. The cultural and ethnic diversity of the area also made a contribution to the demise of the program.
Working as a care manager for a health plan that is contracted to administer state funded Medicaid programs, I am responsible for coordinating care for the managed Medicaid population in our county. An example of a problem we frequently encounter is a case where a patient requires specialty care that can only be provided by a facility in another community. Based on medical necessity, there is no question that the care is appropriate, and that the health plan will authorize the necessary visits. The problem arises when the patient is unable to obtain transportation to the designated facility and has no assistance from family or friends. The patient is unable to afford an expensive taxi ride, and due to his medical condition, is unable to utilize public transportation. State Medicaid does not cover non-emergent transportation, yet under State rules, the health plan is mandated to provide the patient with this service. The health plan is then obligated to make some type of arrangement for transportation, whether it be taxi vouchers, an agreement with a private transportation company, or authorization for non-emergent ambulance transportation, without hope of reimbursement from the State. It is not realistic to expect a health plan to absorb these types of costs and remain financially sound.
There is little doubt that our nation's current health care delivery system is in need of an overhaul. Our current system is like a loosely jointed puppet, providing care that is fragmented. There is often so little continuity in the care provided among all of the various specialties, that there are times when the left hand truly has no idea what the right hand is doing. Patients with chronic diseases are treated for their acute problems, with different specialties treating only the part of the whole that is their area of expertise, while paying little attention to the individual as a complete human being. Additionally, delivery of care is centered on high cost institutional settings rather than less expensive community settings. There is a push to change the current process; to shift the focus away from component based crisis management to a system of preventive care. The federal government has even jumped onto the bandwagon with the Healthy People 2010 initiative, which calls for a national "refocusing of health policies and expenditures on the long-term investment for a lifetime of good health".3 There is little doubt that such a system could decrease costs and raise the overall quality of life for everyone in this country. The question remains as to how we, as a nation, can bring about the needed changes. One thing is clear, that until all of these issues are closely examined and addressed, there can be little chance of success.
©1999 The American Institute of Outcomes-Case Management
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