Abstract
Care management of high-cost/high-needs patients is an increasingly common strategy to reduce healthcare costs. A variety of targeting methodologies have emerged to identify patients with high historical or predicted healthcare utilization, but the more pertinent question for program planners is how to identify those who are most likely to benefit from care management intervention. This paper describes the evolution of complex care management targeting strategies in Community Care of North Carolina’s (CCNC) work with the statewide non-dual Medicaid population, culminating in the development of an “Impactability Score” that uses administrative data to predict achievable savings. It describes CCNC’s pragmatic approach for estimating intervention effects in a historical cohort of 23,455 individuals, using a control population of 14,839 to determine expected spending at an individual level, against which actual spending could be compared. The actual-to-expected spending difference was then used as the dependent variable in a multivariate model to determine the predictive contribution of a multitude of demographic, clinical, and utilization characteristics. The coefficients from this model yielded the information required to build predictive models for prospective use. Model variables related to medication adherence and historical utilization unexplained by disease burden proved to be more important predictors of impactability than any given diagnosis or event, disease profile, or overall costs of care. Comparison of this approach to alternative targeting strategies (emergency department super-utilizers, inpatient super-utilizers, or patients with highest Hierarchical Condition Category risk scores) suggests a 2- to 3-fold higher return on investment using impactability-based targeting.
Insights Results
Overview of article/program
This paper describes the evolution of complex care management targeting strategies in Community Care of North Carolina’s (CCNC) work with the statewide non-dual Medicaid population, culminating in the development of an ‘‘Impactability Score’’ that uses administrative data to predict achievable savings.
Community Care of North Carolina (CNCC) complex care management (CCM) program began under a legislative mandate in 2009. CNCC care managers comprehensively assess health status, knowledge, and behaviors; gaps in care; self-management capabilities and support network; social and financial barriers; and the goals of the patients
Initially, patients were identified for CCM in a variety of ways, most commonly by referral from the primary care provider or hospital. Claims-based reports identified additional priority patients through a clinical algorithm that initially assigned points based on a number of risk factors, including: top cost percentile; presence of diabetes, asthma, heart failure, or chronic obstructive pulmonary disease (COPD); presence of multiple chronic conditions; behavioral health comorbidity; 3 or more outpatient providers; 8 or more medications, and count of prior ED and inpatient visits. This scoring system was phased out when an indicator of expected costs related to potentially preventable hospital visits was introduced in 2011, and additional indicators of predicted 12-month risk of hospitalization and predicted risk of drug therapy problems were introduced in 2013. These indicators, intended to identify patients likely to benefit from care management to inform outreach priorities, were available to local care management teams within a web-based Care Management Information System and in ‘‘priority patient list’’ reports updated quarterly
Upon engagement of patients identified as priority for care management outreach, CCNC care managers comprehensively assess health status, knowledge, and behaviors; gaps in care; self-management capabilities and support network; social and financial barriers; and the goals of the patient. Care management interventions are individualized to the needs of the patient, but commonly involve medication review and reconciliation, facilitating communication with the primary care provider and specialists, motivational interviewing, health coaching and patient/caregiver education, and linkage to community resources
The CCM program operates within a fixed budget under capitated management fees from the state Medicaid agency such that demand for care management services has consistently exceeded capacity
Methods
The authors identified 23,455 non-dual, continuously eligible, CCNC-enrolled Medicaid beneficiaries who received some level of care management between October 2011 and September 2012, and had at least 1 potentially preventable admission, readmission, or ED visit in the year prior to initiation of care management. Control subjects were selected from a historical period, January-December 2010, during which CCNC’s CCM program was not yet fully to scale. Control subjects were a sample of 14,839 continuously eligible, CCNC-enrolled Medicaid beneficiaries who had at least 1 potentially preventable admission, readmission, or ED visit during the year but were not approached for care management during that year or through 6 months of follow-up, to June 2011
Authors developed “Impactability score,” which uses administrative data to predict achievable savings impact that are attributable to care management interventions at the individual patient level as part of the analysis. Model variables include medication adherence, historical utilization and unexplained by disease burden
Results
Findings suggest that not all high-cost patients have high Impactability scores, and not all patients with high Impactability scores have high costs
Patients who received care management experienced a reduction in spending that was greater than the change in spend observed in their respective comparison groups
Difference-in-difference analysis estimated a care management savings impact of $5,922 per patient over the 6-month follow-up period for patients with the highest CCM Impactability Scores, compared to $2,748 for ED super-utilizers, $2,178 for inpatient super-utilizers, $1,650 for highest HCC scores, and $1,470 for patients with any prior inpatient or ED use
The top 3 social factors that made patients eligible for CCM were mental illness, unstable support system, and lack of transportation. 67% of patients engaged in CCM had a mental illness, 23% had unstable support system, and 21% lacked transportation. Many also had 2 or more social risk factors
Key takeaways/implications
CCNC’s experience reveals that ‘‘high-cost/ high-needs’’ is not the same thing as ‘‘highly impactable.’’ Targeting strategies that seek to identify patients based on high current or predicted costs or utilization are likely to identify large numbers of individuals whose health care needs will not be meaningfully altered by care management intervention. Conversely, many individuals at the lower end of the cost spectrum may benefit substantially
Analyses suggest that the return on investment from care management intervention is 2- to 3-fold higher with Impactability-based targeting compared to these more common approaches
Impactability-based targeting using administrative data alone provides an efficient first-pass screening mechanism, to allow for more focused outreach by care management teams to the small percentage of the population most likely to benefit
Areas for future research: 1) Approaches to real-world program evaluation; 2) Potential for care management to address impact beyond cost (what works/doesn’t work); and 3) Analytic strategies for models
