Bell JF, Krupski A, Joesch JM, West II, Atkins DC, Court B, Mancuso D, Roy-Byrne P
OBJECTIVE: To evaluate outcomes of a registered nurse-led care management intervention for disabled Medicaid beneficiaries with high healthcare costs.
DATA SOURCES/STUDY SETTING: Washington State Department of Social and Health Services Client Outcomes Database, 2008-2011.
STUDY DESIGN: In a randomized controlled trial with intent-to-treat analysis, outcomes were compared for the intervention (n = 557) and control groups (n = 563). A quasi-experimental subanalysis compared outcomes for program participants (n = 251) and propensity score-matched controls (n = 251).
DATA COLLECTION/ EXTRACTION
METHODS: Administrative data were linked to describe costs and use of health services, criminal activity, homelessness, and death.
Principal findings: In the intent-to-treat analysis, the intervention group had higher odds of outpatient mental health service use and higher prescription drug costs than controls in the post period. In the subanalysis, participants had fewer unplanned hospital admissions and lower associated costs; higher prescription drug costs; higher odds of long-term care service use; higher drug/alcohol treatment costs; and lower odds of homelessness.
CONCLUSIONS: We found no healthcare cost savings for disabled Medicaid beneficiaries randomized to intensive care management. Among participants, care management may have the potential to increase access to needed care, slow growth in the number and therefore cost of unplanned hospitalizations, and prevent homelessness. These findings apply to start-up care management programs targeted at high-cost, high-risk Medicaid populations.
Overview of model/article
KCCP is a community-based, RN-led care management intervention that delivers services to disabled Medicaid beneficiaries with mental health and/or substance use disorder (SUD) and who were determined to be at risk for high future healthcare costs. The program aims to address social and healthcare needs and to enhance care coordination, communication, and integration of services
KCCP participants received intensive care management from a team comprised of 4 full-time RNs, 2 MSWs, and a chemical dependency counselor, all of whom had been trained in motivational interviewing, attending regular trainings, received ongoing clinical supervision, participated in weekly case-conferences, and participated in monthly meetings with community-based organizations
Participants completed 60-90 minute in-person assessments of medical and social needs and collaboratively set goals. Throughout the program, team members provided each participant with self-management coaching, monitoring (in-person and virtual), care coordination, and linkages to community resources
Methods of article
Participants were defined as individuals who were enrolled in the Medicaid Categorically Needy Program, King County resident, evidence of at least 1 physical condition and mental health problem, and predicted healthcare costs at least 50% higher than average Medicaid SSI recipients, using PRISM
1380 were randomly assigned to either the intervention or wait list group. Before the trial began 133 were excluded from the intervention and 123 were excluded from the control group because they were deemed ineligible
The study employed intensive outreach efforts to update addresses, highlight services, and achieve phone contact. 68% of cases contacted did not yield a response
After initial ITT analyses were not successful, researchers used a quasi-experimental design to assess the impact of the KCCP intervention for active intervention participants (n = 251) versus a propensity score-matched comparison group (n = 251)
Estimates did not differ significantly for most outcomes. Exceptions included higher monthly prescription drug costs by $74; 30% greater odds of outpatient mental health visits (p < .01); and 95 % higher odds of criminal conviction (p = .02) in the intervention group. In addition, the negative binomial model results indicated the intervention group had a higher rate of inpatient admissions without an ED visit than controls
Participants had, on average, 2 fewer inpatient medical admissions preceded by an ED visit per 100 months and associated monthly costs were lower by $321 relative to the comparison group
Participants had higher average monthly costs for prescription medications by $148 relative to the comparison group (p = .05). Participants also had greater odds of long-term care costs than the comparison group (OR = 1.36; p = .04)
Lack of savings is consistent with other Medicaid coordinated care programs, such as MCCDP. Research indicates costs must be $125-150/participant to generate net savings
However, several outcomes indicated improved access to care, including increased use of prescription drugs, increase use of LTSS, and increased drug/alcohol treatment costs