Abstract
This review focused on the 100 MassHealth members and 99 HSN users who had the highest number of paid claims during fiscal year 2013. The 100 MassHealth members collectively had 69,305 paid claims that covered approximately 200,000 services, totaling over $16 million, or an average of $164,000 per person. The 99 HSN users collectively had 19,316 paid claims that covered over 39,000 services, totaling approximately $5.79 million, or an average of $58,000 per person.4 Some of these individuals had catastrophic injuries or illnesses, but many have chronic conditions that require regular, ongoing care. The review’s broad goal
was to understand what programs are, or could be, in place to ensure that super-utilizers are receiving clinically appropriate services delivered in a cost-effective manner, as well as to identify whether there are opportunities for MassHealth to improve its program integrity activities and reduce the potential for fraud, waste, or abuse that increases super-utilizers’ healthcare costs
Insights Results
Overview of articles/programs
This is a review of super-utilizers in Massachusetts’s Medicaid (i.e., MassHealth) and Health Safety Net programs and opportunities to improve care for these populations
MassHealth launched One Care in partnership with the federal government. This program focuses on addressing the healthcare needs of dual-eligible adults between the ages of 18 and 65. The purpose of the program is to link the benefit structures for dual eligibles to allow for better coordination of care, more streamlined service delivery and reimbursement processes, and lower costs. In its earlier states, the program resulted in substantial financial losses for private insurers, yet many private payers are still working to find ways to “fix” the program
Massachusetts’ Money Follows the Person demonstration, a joint federal-state initiative, targets a subset of MassHealth super-utilizers aiming to provide more appropriate and cost-effective care in a community setting. First year of implementation resulted in a 20% decrease in expenditure for enrollees
Through the Massachusetts Behavioral Health Partnership (MBHP), MassHealth provides integrated care management services to “high-risk individuals”. The program identifies high-risk individuals through claims data using a predictive modeling tool that flags those with complex medical, mental health or substance abuse disorders. The program also includes supplementing a primary care provider’s team with services such as home assessments, care coordination among different providers and agencies, assistance with appointment reminders and transportation arrangements and education to help patients comply with medication regimens. MBHP reports that providers have felt well-equipped to meet the needs of their general patient population, however, they do not have the capacity to perform the extensive care management that high-utilizing and medically complex patients require
Celticare is a Medicaid managed care model administering services for the Massachusetts Medicaid population, specifically addressing the needs of super-utilizers. Celticare runs monthly queries of its database to generate reports that identify individuals with the highest total medical spending, individuals with the most emergency department visits and individuals at high risk of resource utilization due to physician and behavioral health issues. Celticare then assesses all of these members for clinical need and then coordinates with providers to conduct face-to-face interventions when necessary. They are conducting several small scale initiatives in selected service areas to identify different approaches to managing super-utilizers
Methods of article
This review was conducted using MassHealth and HSDN claims data to understand the services these individuals received. Using this data, the Office of MassHealth identified potential gaps in care for individuals for whom MassHealth and the HSN program could take steps to reduce the cost of care, reduce unnecessary services, improve quality of care and reduce inappropriate billing. A review team reviewed the reports and identified individuals as “potentially actionable”. These patients reported 1 or more of the following opportunities in their profile: 1) Care coordination for individuals with chronic diseases and conditions; 2) Improved patient compliance for individuals with chronic diseases and conditions; 3) Behavioral healthcare coordination, enhancement and improved patient compliance; or 4) Substance abuse care coordination, care enhancement, and improved patient compliance
Results
The majority (78 out of 100) of the MassHealth members presented potentially actionable utilization patterns. Of these 78 MassHealth members, 53 would benefit from increased care coordination. For example, there was high utilization of emergency departments for conditions that can be addressed in a lower-cost setting (e.g., sprains, respiratory infections). Sufficient care coordination for these MassHealth members could have helped to: 1) Reduce care in high-cost settings by diverting potential emergency department visits to office visits; 2) Encourage members to seek care from a consistent group of providers; and 3) Manage community-based services such as home health services to ensure that they are medically necessary and clinically appropriate
For the HSN program, 19 out of 99 of users presented potentially actionable patterns. As with MassHealth beneficiaries, care coordination opportunities for HSN users with chronic conditions was the most common reason for an actionable pattern, but was typically only one of several reasons. The HSN users presented patterns that included high numbers of inpatient stays, multiple emergency department visits for the same condition, and care received at multiple hospitals by different providers. Proactively seeking out HSN users with a history of receiving large amounts of healthcare treatment for which the HSN program reimburses providers could create opportunities to improve care coordination. However, it is important to recognize that the HSN program is fundamentally different from MassHealth. MassHealth is an insurance program that has a relatively consistent group of members whereas the HSN program reimburses hospitals and community health centers for healthcare services provided to uninsured and underinsured patients, many of whom only intermittently receive services for which the HSN program reimburses providers
Key takeaways/implications
Common themes and features of existing programs include: 1) Programs that serve as extensions of provider care settings appear to be beneficial with a focus on adding services to existing provider activities rather than implementing a parallel program that may duplicate or disrupt care already in place; 2) It is important to carefully identify a super-utilizer population and tailor an intervention to that population’s needs; 3) Most of the programs reviewed include a component that facilitates connections between healthcare services and other stabilizing services (e.g., housing, income); and 4) It is essential to engage healthcare providers in designing programs to address the needs of super-utilizers
It appears that MassHealth and the HSN program have the potential to provide quality, cost-effective care coordination that is necessary to achieve good health outcomes and contain related costs. For example, there were many individuals who appeared to have late-stage cancer, but a relatively small number of claims for hospital inpatient or emergency room care
There are 3 relevant recommendations for MassHealth and the HSDN program: 1) MassHealth should consider participating in the CMS Health Home Program – Participation in the Health Home program would enable Massachusetts to access additional resources that would improve the quality and efficiency of service delivery to super-utilizers. Participation in the Health Home program would also provide enhanced federal funding. MassHealth reports that it is currently preparing a request that it will send to CMS and planned to submit its request by June 2016; 2) MassHealth should seek out an administrative partnership with Medicare to increase coordination of care and enhance its claim review – MassHealth would benefit if it could strengthen its information-sharing and administrative strategies with the Medicare program. This partnership would allow MassHealth to better assess its dual eligible members in light of all the services that they receive; and 3) The HSN program should consider implementing demonstration projects to reduce payments to acute care hospitals – Demonstration programs like a prior HSN- funded demonstration that aimed to reduce unnecessary emergency department utilization, such as establishing a 24-hour nurse hotline for a community health center, could improve the efficiency and quality of care for HSN super-utilizers
Although the focus of this review was super-utilizers, the issues the Office identified concerning claims processing and program integrity are systemic and apply to the entire MassHealth system and HSN program. Similarly, MassHealth and the HSN program have the opportunity to utilize their data to detect trends in the use of a variety of healthcare services for all MassHealth members and HSN users, to reduce unnecessary or fraudulent services, and to work with+Q120 their members and users to improve the coordination and quality of their healthcare
Other models in other states targeting super utilizers and may be used to inform development of other programs include:
Camden Coalition of Healthcare Providers (CCHP), in Camden, New Jersey, Link2Care program is a community-based model with care management teams that connect with hospitalized patients, stabilize them for transition to home and then continue to connect with them for a set period of time. The goal of the program is to ensure that these patients have continued access to low-cost care settings (e.g., outpatient behavioral health). The Link2Care program has encountered several of the barriers typically presented by a high-utilizing population and reports that it has identified strategies to address those barriers. For example, care management teams were originally led by higher-cost professional staff, such as registered nurses. However, when it became apparent that the majority of super-utilizers were more likely to need assistance with filling out housing forms rather than clinical expertise, the program changed its approach. Care management teams now include lower-cost staff, such as licensed practical nurses, community health workers, and peer health coaches. The Link2Care program reports that this change has lowered the cost of the Link2Care program and enabled it to expand further into the communities served by CCHP. The program is also tracking the number of patients who have an outpatient follow-up visit within 7 days of an inpatient discharge, proportion of patients who are readmitted to an inpatient facility within 30 days of discharge and more, all indicators of whether the program is meeting its objectives. The healthcare providers participating in the Link2Care program were not initially part of the same network. To address this challenge, CCHP not only coordinates care across providers for individual patients enrolled in the program, it also holds periodic meetings for providers to discuss concerns and barriers to effective super-utilizer care, as well as to brainstorm potential solutions. According to CCHP, through these efforts, providers have built relationships with one another to better address the needs of super-utilizers. One of the factors that CCHP reports is critical to its program is its effort to engage stakeholders in the Camden community, including religious organizations, social service agencies, private volunteer and aid groups, and providers from multiple care settings. Community engagement is critical because super-utilizers often have needs that go beyond the healthcare system and there may be unique assistance available in – or challenges facing – a particular community about which healthcare providers may be unaware. Potential savings of the program are currently being evaluated but anecdotally, providers have seen a positive impact on patient utilization of services and other outcomes. One potential area that CCHP is exploring is the earlier identification of potential super-utilizers by targeting individuals with diagnoses that are more difficult to treat in later stages
Washington state’s Medicaid “Health Home” program model was implemented to address the needs of its super-utilizer population. The program allows state Medicaid agencies to designate networks of service providers to meet the primary, mental health, and long-term services and support (LTSS) needs of super-utilizers
Washington state’s Chronic Care Management (CCM) program reports that it had the highest return on investment of the 3 models tested, returning $1.15 for every $1.00 spent on the program. The CCM program used nurse care managers to coordinate care for a subset of disabled Medicaid beneficiaries who had functional limitations, received in-home personal care, and had cost-based risk scores in the top 20% of disabled beneficiaries. The stated objective of the program was to improve the quality and efficiency of care by coordinating care across providers, educating beneficiaries about their health, and helping beneficiaries set and achieve goals for self-management. Early results from the program have highlighted the needs of enrollees for coordinated care beyond medical services, including treatment for substance abuse, serious mental illness or developmental disabilities, and long-term care. One challenge Washington has encountered in expanding the CCM beyond the elderly and disabled population to a broader population of super-utilizers is engaging Medicaid recipients. In particular, the state found that younger disabled beneficiaries typically had unstable housing situations, making it difficult for Health Home teams and care coordinators to maintain consistent contact with them to manage their care. Going forward, Washington plans to enhance its beneficiary contact information databases by collaborating with other state social service agencies, and provide additional training to care coordinators around connecting Medicaid beneficiaries to housing programs
Minnesota’s Dual Eligibles Program seeks to coordinate administrative functions between Medicare, Medicare Advantage and Medicaid to save money in program operation. Minnesota and the federal government will partner to streamline the enrollment processes, the quality measurement and reporting requirements, and reimbursement policies. One of the challenges Minnesota has encountered in developing its program for dual eligibles is how to fairly allocate any cost savings between the Medicaid and Medicare programs
