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The American Journal of Managed Care December 2019
Clinical Characteristics and Treatment Patterns Among US Patients With HIV
Julie L. Priest, MSPH; Tanya Burton, PhD; Cori Blauer-Peterson, MPH; Kate Andrade, MPH; and Alan Oglesby, MPH
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Terry E. Hill, MD
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Preventive/Office Visit Patient Knowledge and Their Insurance Information Gathering Perceptions
Evan K. Perrault, PhD; Katie J. Schmitz, BA; Grace M. Hildenbrand, MA; and Seth P. McCullock, MA
Cost-Sharing Payments for Out-of-Network Care in Commercially Insured Adults
Wendy Yi Xu, PhD; Bryan E. Dowd, PhD; Macarius M. Donneyong, PhD; Yiting Li, PhD; and Sheldon M. Retchin, MD, MSPH
Benzodiazepine and Unhealthy Alcohol Use Among Adult Outpatients
Matthew E. Hirschtritt, MD, MPH; Vanessa A. Palzes, MPH; Andrea H. Kline-Simon, MS; Kurt Kroenke, MD; Cynthia I. Campbell, PhD, MPH; and Stacy A. Sterling, DrPH, MSW
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Ted A. Skolarus, MD, MPH; Casey A. Dauw, MD; Karen E. Fowler, MPH; Jason D. Mann, MSA; Steven J. Bernstein, MD, MPH; and Jennifer Meddings, MD, MS
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Heidi C. Waters, PhD, MBA; Charles Ruetsch, PhD; and Joseph Tkacz, MS
Cost Burden of Hepatitis C Virus Treatment in Commercially Insured Patients
Christine Y. Lu, PhD; Dennis Ross-Degnan, ScD; Fang Zhang, PhD; Robert LeCates, MA; Caitlin Lupton, MSc; Michael Sherman, MD; and Anita Wagner, PharmD
Delivery System Performance as Financial Risk Varies
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Association of Care Management Intensity With Healthcare Utilization in an All-Condition Care Management Program
Hussain S. Lalani, MD; Patti L. Ephraim, MPH; Arielle Apfel, MPH; Hsin-Chieh Yeh, PhD; Nowella Durkin; Lindsay Andon, MSPH; Linda Dunbar, PhD; Lawrence J. Appel, MD; and Felicia Hill-Briggs, PhD; for the Johns Hopkins Community Health Partnership

Association of Care Management Intensity With Healthcare Utilization in an All-Condition Care Management Program

Hussain S. Lalani, MD; Patti L. Ephraim, MPH; Arielle Apfel, MPH; Hsin-Chieh Yeh, PhD; Nowella Durkin; Lindsay Andon, MSPH; Linda Dunbar, PhD; Lawrence J. Appel, MD; and Felicia Hill-Briggs, PhD; for the Johns Hopkins Community Health Partnership
Higher intensity of care management in an all-condition program addressing care coordination and care barriers was associated with increased healthcare utilization among Medicaid and Medicare patients.
RESULTS

Program Enrollment

A total of 4401 patients were determined to be eligible for care management. Of these, 3665 patients (83%) received a structured “barriers to care” assessment and were enrolled in the program. Of those enrolled, 3604 patients (98%) had claims data and were included in this analysis.

Table 1 shows patient characteristics at baseline. Both Medicaid and Medicare patients were predominantly female. The majority of Medicaid patients were African American, and the majority of Medicare patients were Caucasian. As expected, Medicare patients were older than Medicaid patients and had a higher burden of clinical comorbidities.

Table 2 shows patient characteristics by program contact intensity. The majority of Medicaid (68%) and Medicare (64%) patients received low CM–low CHW program intensity. Among Medicaid patients, age differed by program intensity, with the highest median age in the high CM–low CHW group. There was no relationship between program intensity and sex, race, or clinical comorbidities. Among Medicare patients, the baseline characteristics differed by program intensity: age, with highest median age in the low CM–low CHW group; race, with the highest percentage of African Americans in the low CM–high CHW group; and clinical comorbidities, as Medicare patients in the high CM–high CHW category had the highest percentage of obesity (56%), whereas the low CM–low CHW group had the highest percentage of lipid disorder (54%) and hypertension (74%). There was no relationship between sex and program intensity in Medicare. In both Medicaid and Medicare, the highest percentage of direct referrals to the care management program was seen in the high CM–high CHW category. Demographic characteristics stratified by insurance and CM or CHW categories are included in eAppendix Tables 2 and 3.

Patient Risk of Hospitalization, Barriers to Care, and Program Intensity

Table 3 shows ACG risk scores and barriers to care. The median ACG risk score differed by program intensity within Medicaid (P = .003) and Medicare (P = .007). For both insurance groups, the most intensive program category, high CM–high CHW, had the highest median ACG risk score, indicating that patients with the highest risk of hospitalization received the highest intensity of program contacts. Transportation was the most common barrier and differed in frequency among program intensity. Unstable housing was common among Medicaid patients, and the inability to pay for medications and accessing healthy food were frequent barriers regardless of health insurance.

Modality and Number of CM and CHW Contacts

The median numbers of successful CM contacts per 12 months enrolled in care management were 5.8 and 5.2 for Medicaid and Medicare patients, respectively (Table 4). Similarly, the median total CHW contacts per 12 months enrolled were 6.7 for Medicaid patients and 6.3 for Medicare patients. The majority of successful contacts were via telephone (70% for CM; 68% for CHW). Medicaid patients in the high CM–high CHW group had medians of 17.1 CM contacts and 19.6 CHW contacts per 12 months enrolled. Medicare patients in the high CM–high CHW group had comparable medians of 20.6 CM and 18.8 CHW contacts per 12 months. Data per month are displayed in eAppendix Table 4.

Crude Changes in Healthcare Utilization Outcomes From Baseline

Crude rates of ED visits, hospital admissions, and hospital readmissions per month are included in eAppendix Table 5 (A-C). Overall, the crude hospitalization rate decreased by 10.9% (95% CI, –18.7% to –2.3%) among Medicaid patients and increased by 12.6% (95% CI, 4.2%-21.7%) among Medicare patients.

Adjusted Changes in Healthcare Utilization Outcomes From Baseline

The Figure displays the adjusted relative risk (RR) of ED visits, hospitalizations, and 30-day readmissions in Medicaid and Medicare by program intensity. Medicaid patients in the high CM–high CHW and high CM–low CHW program intensities had a higher adjusted risk of hospitalization (RR, 2.08 and 1.72, respectively [both P <.001]) after program implementation compared with the reference group. Meanwhile, Medicaid patients in the high CM–high CHW program intensity had a higher adjusted risk of 30-day hospital readmission (RR, 2.19; P = .01) compared with the reference group (eAppendix Table 6). The latter effect remained after controlling for comorbidities and clinic site (eAppendix Table 7).

Among Medicare patients, those who received the low CM–high CHW program intensity had a higher adjusted risk of ED visits (RR, 1.33; P = .001) than the reference group. Patients in the high CM–high CHW and high CM–low CHW program intensities had a higher adjusted risk of hospitalization (RR, 1.39 [P = .001] and 1.44 [P <.001], respectively), whereas those in the high CM–low CHW program intensity had a higher adjusted risk of 30-day hospital readmission (RR, 2.20; P = .01) than the reference group.


 
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