Strategies to Reduce Costs and Improve Care for High-Utilizing Medicaid Patients: Reflections on Pioneering Programs

Bodenheimer T
Publication Year: 2013
Patient Need Addressed: Behavioral health, Chronic Conditions, Homelessness/housing
Population Focus: Complex care, Medicaid beneficiaries
Type of Literature: Grey

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.

Insights Results

Overview of brief

  • This brief reports on findings from a review of 14 programs for high-utilizing, complex patients, with a primary focus on Medicaid
  • The programs evaluated are all hybrids of more than 1 model including: health plan, primary care , ambulatory intensive caring unit (aICU), hospital discharge, emergency department-based, home-based, housing first, and community-based
  • Based on the evaluation, 10 key reflections emerged regarding high-utilizer programs: 1) High-utilizer programs can make substantial reductions in hospital admissions, hospital days, ED visits, and total costs of care. However, more work is needed to evaluate Medicaid-only programs; 2) For homeless or precariously housed people, providing permanent housing with case management – with no medical personnel – appears to be the most powerful way to reduce costly healthcare; 3) There is a big difference between the aICU model – referring high-utilizing complex patients to a specialized team with a small panel size — and the primary care model; 4) There is no standard composition of care management teams. Who is on the team depends on the characteristics of the patients being served, but most teams include a registered nurse and social worker. Having a psychiatrist and a pharmacist to work with the care management team is helpful. Some programs have non-professional personnel such as navigators or health coaches, who can assist the professional team members and allow caseloads to increase; 5) Most programs perform a careful initial assessment, develop a care plan and incorporate regular follow-up by the care management team; 6) Programs tend to have a coaching rather than a rescuing philosophy. Rather than doing everything for their patients, they attempt to teach patients to better self-manage their health, their social problems, and their ability to navigate the health and social services systems; 7) Many programs have a home visit component with many people working in the programs feeling that home visits are very important; 8) Some programs allow patients to access the care management team 24/7 while others do not. A system like this may be a more effective way to reduce unnecessary ambulance and emergency department use; 9) Coaching patients to understand their medications and to become more medication adherent is an essential feature of all programs. Additionally, many of these patients have historically lacked strong communication channels with prescribing providers; and 10) Caseloads vary with team size, team composition and patient complexity

    Key takeaways/implications

    • Three of the programs that were reviewed appear to have reliable data and were relevant to the Medicaid population:
      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
    • While on the surface the programs reviewed look very different, all share a common set of high-touch, highly focused care management principles. Much still needs to be done to fully understand how to best structure care approaches for this population. Nonetheless, the programs reviewed offer valuable insights into how to improve care and stem excessive spending for Medicaid’s highest-cost subsets