Strategies to Reduce Costs and Improve Care for High-Utilizing Medicaid Patients: Reflections on Pioneering Programs
Across the country, Medicaid stakeholders are exploring new ways to address the needs of the program’s highest-utilizing patients. Super-utilizers make up only five % of the Medicaid universe, yet these patients with complex needs account for more than 50 % of overall program spending. This brief offers important insights for states, health plans, and providers looking to improve care delivery for Medicaid’s sickest, costliest patients. Author Thomas Bodenheimer, MD, MPH of the University of California San Francisco reports on a national review of 14 super-utilizer programs undertaken to help guide the San Francisco Health Plan in designing better ways to care for high-risk, hard-to-reach patients. The majority of the programs analyzed involve Medicaid patients, but the review also examined programs for employed individuals and Medicare that offer potential relevance to Medicaid. The brief outlines 10 key factors for success for high-utilizer complex care management programs and details core features as well as available cost and utilization data for the programs analyzed. While much remains to be done to understand how to best structure care approaches for Medicaid’s high-utilizing patients, the findings in this brief add to the emerging body of evidence regarding high-touch, tailored approaches for this population.
Overview of brief
1) The Chicago Housing First program was also a randomized controlled trial, showing that utilization for the intervention group (who received stable housing and non-medical case management), adjusted for baseline characteristics, was significantly lower than for the control group. This program provides good evidence on what works for homeless or precariously housed patients who are on Medicaid or uninsured
2) Community Care of North Carolina (CCNC), a program for Medicaid patients, has followed cost and utilization measures for a number of years. High-risk patients enrolled in CCNC were compared with high-risk North Carolina Medicaid patients not enrolled in CCNC. CCNC patients have had lower hospital admissions, ED visits, and total costs compared with non-CCNC patients. While the nonCCNC group is not strictly a matched control group, the CCNC high-risk patients on average have higher clinical risk than the high-risk non-CCNC group, making the cost and utilization reductions in the CCNC group, compared with the non-CCNC group, very believable. Risk-adjusted total costs for fiscal year 2010 were 15 % lower in the CCNC group than in the non-CCNC group. In fiscal year 2010, total savings were $382 million, comparing actual costs with expected costs if all Medicaid patients were not enrolled
3) The Atlantic City Special Care Center demonstrated cost and utilization declines compared to a control group of non-Special Care Center patients, with cost savings of 18% compared with the control group. Because the sample was small, the changes were not statistically significant. The control group was reasonably similar to the Special Care Center patients. Savings were the greatest for the patients with the greatest complexity