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The American Journal of Managed Care February 2020
Care Coordination for Veterans With COPD: A Positive Deviance Study
Ekaterina Anderson, PhD; Renda Soylemez Wiener, MD, MPH; Kirsten Resnick, MS; A. Rani Elwy, PhD; and Seppo T. Rinne, MD, PhD
Expand Predeductible Coverage Without Increasing Premiums or Deductibles
A. Mark Fendrick, MD
From the Editorial Board: Jeffrey D. Dunn, PharmD, MBA
Jeffrey D. Dunn, PharmD, MBA
Do Americans Have the Political Will to Tackle Healthcare Costs? A Q&A With Gail Wilensky, PhD
Interview by Allison Inserro
Risk Adjustment in Home Health Care CAHPS
Lisa M. Lines, PhD, MPH; Wayne L. Anderson, PhD; Harper Gordek, MPH; and Anne E. Kenyon, MBA
Reply to “Risk Adjustment in Home Health Care CAHPS”
Hsueh-Fen Chen, PhD; J. Mick Tilford, PhD; Robert F. Schuldt, MA; and Fei Wan, PhD
Preventive Drug Lists as Tools for Managing Asthma Medication Costs
Melissa B. Gilkey, PhD; Lauren A. Cripps, MA; Rachel S. Gruver, MPH; Deidre V. Washington, PhD; and Alison A. Galbraith, MD, MPH
Co-payment Policies and Breast and Cervical Cancer Screening in Medicaid
Lindsay M. Sabik, PhD; Anushree M. Vichare, PhD; Bassam Dahman, PhD; and Cathy J. Bradley, PhD
Discontinuation of New Hepatitis C Drugs Among Medicare Patients
Jeah Jung, PhD, MPH; Ping Du, MD, PhD; Roger Feldman, PhD; and Thomas Riley III, MD
A Population-Based Assessment of Proton Beam Therapy Utilization in California
Arti Parikh-Patel, PhD, MPH; Cyllene R. Morris, DVM, PhD; Frances B. Maguire, PhD, MPH; Megan E. Daly, MD; and Kenneth W. Kizer, MD, MPH
Racial and Ethnic Disparity in Palliative Care and Hospice Use
Tricia Johnson, PhD; Surrey Walton, PhD; Stacie Levine, MD; Erik Fister, MA; Aliza Baron, MA; and Sean O’Mahony, MB, BCh, BAO
Cost-effectiveness of Brentuximab Vedotin With Chemotherapy in Treatment of CD30-Expressing PTCL
Tatyana Feldman, MD; Denise Zou, MA; Mayvis Rebeira, PhD; Joseph Lee, PhD; Michelle Fanale, MD; Thomas Manley, MD; Shangbang Rao, PhD; Joseph Feliciano, PharmD; Mack Harris, BA; and Anuraag Kansal, PhD
Economic Value of Transcatheter Valve Replacement for Inoperable Aortic Stenosis
Jesse Sussell, PhD; Emma van Eijndhoven, MS, MA; Taylor T. Schwartz, MPH; Suzanne J. Baron, MD, MSc; Christin Thompson, PhD; Seth Clancy, MPH; and Anupam B. Jena, MD, PhD
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Impact of Complex Care Management on Spending and Utilization for High-Need, High-Cost Medicaid Patients
Brian W. Powers, MD, MBA; Farhad Modarai, DO; Sandeep Palakodeti, MD, MPH; Manisha Sharma, MD; Nupur Mehta, MD; Sachin H. Jain, MD, MBA; and Vivek Garg, MD, MBA

Impact of Complex Care Management on Spending and Utilization for High-Need, High-Cost Medicaid Patients

Brian W. Powers, MD, MBA; Farhad Modarai, DO; Sandeep Palakodeti, MD, MPH; Manisha Sharma, MD; Nupur Mehta, MD; Sachin H. Jain, MD, MBA; and Vivek Garg, MD, MBA
Complex care management for high-need, high-cost Medicaid patients significantly reduced total medical expenditures and inpatient utilization in a randomized quality improvement trial.
ABSTRACT

Objectives: Complex care management programs have emerged as a promising model to better care for high-need, high-cost patients. Despite their widespread use, relatively little is known about the impact of these programs in Medicaid populations. This study evaluated the impact of a complex care management program on spending and utilization for high-need, high-cost Medicaid patients.

Study Design: Randomized quality improvement trial conducted at CareMore Health in Memphis, Tennessee. A total of 253 high-need, high-cost Medicaid patients were randomized in a 1:2 ratio to complex care management or usual care.

Methods: Intention-to-treat analysis compared regression-adjusted rates of spending and utilization between patients randomized to the complex care program (n = 71) and those randomized to usual care (n = 127) over the 12 months following randomization. Primary outcomes included total medical expenditures (TME) and inpatient (IP) days. Secondary outcomes included IP admission, emergency department (ED) visits, care center visits, and specialist visits.

Results: Compared with patients randomized to usual care, patients randomized to complex care management had lower TME (adjusted difference, –$7732 per member per year [PMPY]; 95% CI, –$14,914 to –$550; P = .036), fewer IP bed days (adjusted difference, –3.46 PMPY; 95% CI, –4.03 to –2.89; P <.001), fewer IP admissions (adjusted difference, –0.32 PMPY; 95% CI, –0.54 to –0.11; P = .014), and fewer specialist visits (adjusted difference, –1.35 PMPY; 95% CI, –1.98 to 0.73; P <.001). There was no significant impact on care center or ED visits.

Conclusions: Carefully designed and targeted complex care management programs may be an effective approach to caring for high-need, high-cost Medicaid patients.

Am J Manag Care. 2020;26(2):e57-e63
Takeaway Points

A complex care management program for high-need, high-cost Medicaid patients reduced total medical expenditures by 37% and inpatient utilization by 59%. Based on the design of the program, these results suggest that:
  • Carefully designed and targeted complex care management can be effective among high-need, high-cost Medicaid patients.
  • Community health workers and other nontraditional healthcare workers can help engage and activate patients, build trust, and better understand and manage the nonmedical drivers of poor health and avoidable spending.
  • Targeted interventions focused on modifiable risk factors are an effective and efficient approach for reducing unnecessary utilization.
High-need, high-cost patients—those with chronic medical conditions and co-occurring social and behavioral complexity—experience poor health outcomes and high rates of potentially preventable spending.1-8 Improving care quality and lowering spending for this population have become a focus for policy makers, clinicians, payers, and health systems.3,4,8

Complex care management programs—broadly defined as efforts to coordinate medical and social services, assist patients and caregivers in managing medical and behavioral health conditions, and address the psychosocial drivers of poor health—have emerged as a promising model to improve care for high-need, high-cost patients.8-13 In recent years, complex care management programs have been widely adopted by health systems and delivery organizations entering into value-based payment arrangements. A 2018 survey found that 96% of accountable care organizations had implemented complex care management programs for high-need, high-cost patients.14

The impact of complex care management has been uneven. Systematic reviews and large-scale program evaluations have not demonstrated a consistent impact on health outcomes, spending, or acute care utilization.15-17 Some individual programs, however, have led to improvements in patient-reported health and decreases in acute care utilization and total spending.11,15,16,18,19 Program heterogeneity (eg, practice setting, patient characteristics, care models, staffing) may explain these varied results.

Complex care management programs have traditionally been developed and implemented among Medicare populations.11,12,15,16,20 Increasingly, these models are being adopted in Medicaid.14,21-24 Similar to the Medicare population, high-need, high-cost Medicaid patients have high rates of chronic conditions25 and preventable acute care utilization,6,26,27 both attributes well suited to complex care management.13 High-need, high-cost Medicaid patients also have high rates of behavioral health disorders and unmet social needs,6,21,28,29 attributes less common among Medicare patients and areas in which the impact of complex care management is uncertain.

Despite the proliferation of complex care management for Medicaid patients, there have been very few rigorous program evaluations, and the overall effect of these programs is unclear. This paper presents the results of a randomized quality improvement trial to evaluate the impact of complex care management on spending and utilization for high-need, high-cost Medicaid patients with complex health and social needs.

METHODS

Design and Setting

This was a randomized quality improvement trial to evaluate the impact of a complex care management program on spending and utilization for high-need, high-cost Medicaid patients. The design and implementation of the program, detailed in the following paragraphs, incorporated attributes of successful complex care management programs in other populations.8,11,13,20,30 The program was implemented at CareMore Health (CareMore) in Memphis, Tennessee, where CareMore provides comprehensive primary care services for Medicaid patients enrolled in TennCare plans administered by Amerigroup. The program was operated out of a single CareMore care center.

Population

Participants were drawn from adult Medicaid patients attributed to CareMore primary care physicians (PCPs). Program eligibility criteria were aimed at identifying patients at risk for poor outcomes and unnecessary spending, as well as those most likely to benefit from complex care management. The criteria drew from analyses suggesting that combining predictive models, historical claims, and clinician judgment is the most effective approach to identifying patients for complex care management.13,31-34

Eligible patients were first required to meet at least 1 of the following criteria: top 5% of total medical expenditures (TME) in the prior 12 months, top 5% of Chronic Illness Intensity Index (CI3) score, or care team member nomination. The CI3 score is a predictive model developed by Amerigroup that uses demographic, clinical, and pharmacy claims data to estimate a patient’s predicted cost in the subsequent 12 months compared with the average Amerigroup Medicaid patient.

Patients meeting 1 of the above criteria were then required to meet at least 1 of the following criteria: 2 or more inpatient (IP) admissions in the prior 12 months, 3 or more emergency department (ED) visits in the prior 12 months, or 2 or more chronic conditions.

Patients less likely to benefit from complex care management because of specific comorbidities (cognitive impairment, severe mental illness without medical comorbidity, active malignancy, pregnancy) or current residence in a long-term care facility were excluded.

Given limited resources, eligible patients were randomized in a 1:2 ratio to complex care management or usual care. Patients not continuously attributed to CareMore over the 12-month period following randomization were considered lost to follow-up. This could occur for several reasons: loss of Medicaid eligibility, enrollment in another TennCare plan, or transfer of care to a non-CareMore PCP.


 
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