Robert Calandra

Sabra Matovsky met her at a town hall meeting for low-income residents in Riverside, California. The 60-year-old woman was depressed. She was caring for her mentally ill adult son and had recently been diagnosed with diabetes. Her primary care doctor had dutifully loaded her up with educational material—brochures, pamphlets, websites, the name of a support group. But the woman couldn’t deal with it.

“She was overwhelmed. Her health care really took a back seat to dealing with her son’s issues,” says Matovsky, the executive vice president of Integrated Health Partners, a consortium of 11 federally qualified health centers caring for more than 500,000 Medi-Cal patients in San Diego and Riverside counties (Medi-Cal is California’s Medicaid program).

What motivates patients?

It wasn’t till she found help at a community health center that she was able to take control of her life—and her health problems, says Matovksy. One of the programs at the center, Medi-Cal’s MediConnect, connects high-risk Medicaid (and Medicare) beneficiaries with care managers. That kind of matchmaking has been going on for years, but the goal now is to gain some insight into the motivations of patients, says Matovsky: “By working more through a motivational interviewing technique you figure out what is important to them and help them devise a plan to get where they need to go.”

Sabra Matovsky

A motivational interviewing technique allows providers to devise a plan for diabetes patients that can help them “get where they need to go,” says Sabra Matovsky of Integrated Health Partners.

If there is a pecking order to diseases, diabetes is not at the top of it. Heart disease and cancer take those honors in most domains (funding, sophistication of the treatments, charity). But in terms of expense, diabetes is in their league. The cost of diabetes (including undiagnosed cases) in 2012 exceeded $322 billion, according to a study published in Diabetes Care a couple of years ago. A report for the American Diabetes Association estimated direct medical costs of the disease to be $176 billion, less than the $193 billion spent on heart disease but more than the $157 billion for cancer. Complications, such as blindness, kidney disease, and amputations, are a major factor in the cost of diabetes. By some accounts, a beneficiary with diabetes costs an insurer, on average, about 3 times more per year than a beneficiary without the disease.

Medicaid officials and Medicaid managed care plans have been eyeing figures like that with some trepidation as Medicaid has expanded under the ACA. According to Kaiser’s latest tally, 31 states and the District of Columbia have expanded Medicaid. A 2012 Kaiser Family Foundation report on Medicaid and diabetes reported that the prevalence of diabetes among Medicaid beneficiaries was almost twice as high as it was among the uninsured (9% vs. 5%), but the Kaiser experts noted that part of the difference was a higher rate of undiagnosed diabetes among the un­insured. In a 2012 Health Affairs article, a pair of Kaiser researchers, Rachel Garfield and Anthony Damico, wrote: “Uninsured adults with diabetes who gain Medicaid coverage under health reform are likely to enter the program with unmet needs, and coverage is likely to result in both improved access and increased use of health care.”

And that appears to be what’s happening.

Quest Diagnostics, which performs laboratory tests for 1 in 3 adult Americans and half the physicians and hospitals in the United States, analyzed data for 434,288 patients aged 19 to 24. It found that states expanding Medicaid under the ACA had a 23% higher rate of newly identified patients with diabetes in the first six months of 2014 compared with the first six months of 2013 (before expansion).

States that did not expand Medicaid had less than a 1% increase in the newly identified Medicaid beneficiaries with diabetes in the first six months of 2014.

Medicaid bump

A study published in the Annals of Internal Medicine in April comparing expansion to nonexpansion also showed that there’s a bump in diabetes diagnoses from Medicaid coverage. Using data from the National Health Interview Survey, the researchers found that in expansion states, the percentage of people who had been diagnosed with diabetes increased from 8.3% to 12.8%, whereas in nonexpansion states, the percentage fell from 9.6% to 8.1%.

Medicaid expansion: Differing experience in expansion and nonexpansion states

Percentage of Medicaid beneficiaries

Preexpansion period was defined as 2010–2013. Post-expansion was the second half of 2014. Results based on data from the National Health Interview Study.

Source: Wherry LR and Miller S et al., Annals of Internal Medicine, April 2016

But there are plenty of advantages to catching diabetes early, notes Patrick Tellez, MD. “Earlier intervention is much less costly and yields better health outcomes for patients” says Tellez, chief medical officer of North County Health Services, one of the centers in the Integrated Health Partners’ network. “That has been shown time and again.”

Tellez has seen firsthand in his own organization both the increase in the number of people diagnosed as well as improved outcomes. About three quarters of the 62,000 people who get care at North County Health Services are Medi-Cal beneficiaries. In 2013, 2,347 of the center’s patients were diagnosed with diabetes; last year that number rose to 3,385.

Philly has a problem

Philadelphia has one of the worst diabetes problems in the country, and Keystone First, the largest Medicaid managed care plan in the area, has responded with a program that encourages eye exams and weight loss. About one in every six adult residents of the city has diabetes, and incidence went up by 50% between 2004 and 2012. Keystone identifies members with diabetes who are not up to date with screenings and gets them caught up. Beneficiaries are enrolled in workshops and given help aimed at cementing relationships with their primary care physicians. According to Keystone First, participants typically lose between 10 and 15 pounds.

“Lifestyle changes, behavior modification, and routine checkups are some of the best ways we can minimize diabetic patient costs and help patients live full, healthy lives,” says Andy Bhugra, director of government health solutions for Navigant, a health care consulting firm with clients that have Medicaid programs. “Physicians are starting to take a more personalized approach to prevention and diabetes management.”

Take for example the woman Matovsky met at the meeting. She is still struggling with her son’s issues. But she has also taken control of her health, regularly attending meetings of a local diabetes support group, according to Matovsky.

For people with diabetes, depression is often an added burden to their health. Simply telling a patient with diabetes that they have to stop smoking, lose weight, eat a better diet, and stop drinking alcohol may add to their sense of hopelessness. Research has also suggested that diabetes may have a direct effect on the brain, changing the neuronal circuits that influence mood and motivation.

That’s why programs like MediConnect employ a team approach to address both physical and behavioral health issues.

“We do warm handoffs to behavioral health so those issues can be addressed in a one-stop shop to enable the person to get a handle on some of the factors affecting their ability to take care of themselves,” says Tellez.

And with more insurance companies managing Medicaid programs, the hope is that they will bring better technology and sophisticated management techniques to bear. “They can invest in better care management—maybe patient-facing mobile technology that enables coaching in a much more connected way and other innovations like telemedicine that improve access to earlier intervention and capitalize on the business opportunity of better management with a focus on patient services,” Tellez says.

Robert Calandra is an independent journalist in Philadelphia with more than 20 years experience writing about health care.