By Melinda Young
EXECUTIVE SUMMARY
One way to reduce costs among a population of high-cost, high-utilization Medicaid patients is to use intensive care management.
- In a study of an intervention involving a nonprofit organization that provides integrated care to complex patients, investigators found a reduction of more than $1,900 in total medical expense per member per month.
- Engagement rates for the program were three times higher than standard care management.
- Nurses met with the care team every two weeks, and provided monthly feedback about patients to primary care providers.
Intensive care management can sharply reduce costs among a population of Medicaid patients with the highest cost and utilization.1
“We were delighted it was successful and reduced the total medical expense per member per month by over $1,900 for those randomized to receive the intervention vs. those randomized to standard care,” says Christine Vogeli, PhD, study co-author and an assistant professor at Harvard Medical School and Massachusetts General Hospital.
There were consistent reductions in ED visits and inpatient admissions. “This was a small pilot to test a new model of providing care to a very complex Medicaid population,” Vogeli explains. “We used a multistep process to identify the person who had the highest costs and the highest modifiable utilization patterns.”
The intervention is expensive, and researchers wanted to use it most efficiently. This meant targeting only those with the highest costs and utilization. “We partnered with a nonprofit organization that specializes in community and home-based services and crisis stabilization care,” Vogeli says. “This was evaluated over a one-year period, and the savings to Medicaid from this program are quite significant.”
A second reason for focusing on complex patients is because engaging with them is difficult. “One of the primary outcomes is engagement rates for the program were three times higher than in standard care management of primary care practices,” Vogeli says.
The vendor providing the care sent the care management team to meet with patients at homeless shelters, coffee shops, at home — wherever was convenient for the patient. The teams included nurse practitioners, social workers, community health workers, physicians, and behavioral health specialists.
It takes that level of outreach and support to realize such positive benefits. “That’s why we decided to partner with a vendor who had those skills,” Vogeli says. “We have our own care management team that is internal, but we recognize that for this small, top percentage of patients — in terms of risk and medical expenses — their problems are so complex, and they’re so poorly aligned with the healthcare system, that we needed a different solution.”
The nonprofit vendor is Commonwealth Care Alliance (CCA), a Boston-based integrated care system that recently extended its evidence-based care model throughout the United States, including in Rhode Island, California, and Michigan.
CCA accessed patients’ medical records, which helped provide seamless care coordination. Care management teams provided transportation to patients and accompanied them to medical visits as needed. Massachusetts’ Medicaid program provides generous medical coverage, but many patients needed help with social determinants of health, including transportation.
CCA is experienced in this type of intensive care management because of the organization’s work with a dual-eligible population, meaning patients who qualify for both Medicaid and Medicare. Now, they have experience working with Medicaid patients who likely will be dual eligible at some point in the future.
“They identify, target, and provide care management to people at that cusp of transitioning from Medicaid to dual eligible, using [a team of] people who have a lot of experience in providing care to that dual-eligible population,” Vogeli says. “They knew the patient’s history, and knew enough about them to find them. A significant amount of resources were spent on patient outreach.”
Nurses met every two weeks with the care team and provided monthly feedback about patients to primary care providers (PCPs). Clinical communication included messaging within the electronic health record. Together, the care management team and PCPs determined the best care plans for these patients.
The monthly meetings with PCPs included a review of clinical cases. This helped ensure seamless communication and opportunities to troubleshoot any operational challenges in providing the intervention.
There always are challenges with new care coordination programs, making problem-solving necessary. “There are unintended situations that come up, and you have to have an avenue to address issues as they come along,” Vogeli says. “This is a hard population, and the people who provide this kind of care are really devoted to providing good care and supporting these highly complex patients.”
While PCPs remained in charge of their patients, the care management team helped patients access community-based services to address complex health-related social needs, including substance use problems, psychosocial challenges, housing, and transportation. Each patient received a comprehensive acute care plan that was placed in their medical record and could be accessed anytime the patient visited the hospital or ED.
“That comprehensive acute care plan provided details on who could be called and other details about the patient’s care plan that CCA had created,” Vogeli says. “It helps emergency physicians.”
For example, if a CCA patient arrives in the ED, the emergency physician (EP) might decide to send the patient home and back into care management team’s supervision. Without the team’s involvement in the patient’s case, the EP might have to hospitalize the patient due to an unstable home environment that makes self-management infeasible.
“We believe that helps to reduce ED visits and hospitalization for these patients,” Vogeli says.
It also reduces the number of tests EPs order because they can see the patient’s care plan. “It really helps decision-making about a patient,” Vogeli says. “We believe that is why we saw ED visits were slightly lower and hospitalizations were lower.”
The cost savings were the most surprising result. “These savings were pretty dramatic,” Vogeli says. “The patients had approximately $6,000 per month in expenses in the prior year.”
But these costs were reduced by an average of more than $1,900 per member, per month among the people on the care management intervention. “This is an expensive program that provides a lot of services, but for our healthcare system we wanted to invest in this program, and we utilized Medicaid funding from the state to allow for some of these experiments,” Vogeli explains. “We found it actually works and reduces medical expense to the state.”
REFERENCE
- Rowe JS, Gulla J, Vienneau M, et al. Intensive care management of a complex Medicaid population: A randomized evaluation. Am J Manag Care 2022;28:430-435.
One way to reduce costs among a population of high-cost, high-utilization Medicaid patients is to use intensive care management. In a study of an intervention involving a nonprofit organization that provides integrated care to complex patients, investigators found a reduction of more than $1,900 in total medical expense per member per month.
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