States Focus on ‘Super-Utilizers’ to Reduce Medicaid Costs

Ollove M
Publication Year: 2014
Patient Need Addressed: Behavioral health, Chronic Conditions
Population Focus: Complex care, Medicaid beneficiaries
Type of Literature: Grey


Insights Results

Overview of article

  • This article briefly describes Medicaid health homes and common needs among patients within Medicaid home
  • Under the ACA, Medicaid for the first time will reimburse healthcare providers to coordinate the care of patients who have more than one serious chronic health condition, such as diabetes, congestive heart disease and dementia, or who have a serious mental illness or a substance abuse addiction. At least 15 states (Alabama, Idaho, Iowa, Maine, Maryland, Missouri, New York, North Carolina, Ohio, Oregon, Rhode Island, South Dakota, Vermont, Washington and Wisconsin) have taken advantage of that provision to establish “health homes,” or teams of providers responsible for coordinating the physical and mental healthcare for these most complicated and costly of patients
  • Although most states have not been operating health homes long enough to report on outcomes, Missouri, which was first to establish health homes in 2012, has achieved measurable results. About 20,000 Missourians with severe mental illnesses are enrolled in health homes geared towards the treatment of behavioral health. It is reported that the health home has sparked dramatic improvements in patients with co-existing conditions, such as hypertension, cholesterol, obesity and diabetes. It is also reported that the program saved nearly $3 million by keeping enrollees out of the hospitals and emergency rooms
  • As a result of these outcomes in Missouri, state Medicaid policymakers elsewhere are expecting similar outcomes in the share of overall healthcare costs attributed to super-utilizers. The article explains that mental illness and drug/alcohol disorders are 2 conditions that are nearly universal among the highest-cost, most frequently hospitalized beneficiaries, suggesting opportunity for behavioral health intervention
  • Specifically, a Rutgers study suggests that New Jersey could save tens of millions in Medicaid spending with better coordination of care for the seriously mentally ill. Under CMS rules, to be eligible for enrollment in a health home, patients must have at least two chronic conditions, one chronic condition and at risk for another, or a serious mental illness or substance use disorder
  • It is important to note that health homes take on different focuses in intervention and target different patient populations in different states (e.g., Ohio’s health homes are geared only for those with serious mental illness while in Wisconsin, participants must have HIV/AIDS plus on other chronic conditions)