Telephone Care Management’s Effectiveness in Coordinating Care for Medicaid Beneficiaries in Managed Care: A Randomized Controlled Study

Insights Results

Overview of article

• Only about 7% of Medicaid beneficiaries are blind and/or disabled, but they account for 40% of Medicaid spending. This group is likely to be a vulnerable and hard-to-reach group that experiences greater difficulty navigating the healthcare system. As a result, many states are looking for cost-effective strategies, including case management, to provide medical services to this population
• Despite the success of care management in some settings, there has not been a rigorous evaluation of this approach in a diverse set of Medicaid beneficiaries with multiple chronic conditions. This article presents results from a randomized study of a telephone care management program for blind and/or disabled Medicaid beneficiaries in Colorado, many of whom often have multiple chronic conditions. Care managers’ first responsibility was to enroll individuals assigned to the intervention group into the care management program

Methods of article

• This study was a randomized control trial with an intervention group (n = 3,540) that was enrolled in managed care with telephone care management and a control group (n = 1,524) who remained in fee-for-service system without care management services. Multi-disciplinary care coordination teams provided telephone services to the intervention group to address patients’ medical and social needs
• Individuals were eligible for the study if they were blind and/or disabled and receiving Medicaid in Colorado through the fee-for-service (FFS) system in five Denver-area counties (Adams, Arapahoe, Boulder, Broomfield, and Weld). Individuals were excluded if they were under 18 or more than 64 years of age, were dually eligible for both Medicare and Medicaid, were in a long-term care facility, or were AIDS or brain injury patients receiving Home and Community Based Services (another Medicaid program available to individuals with disabilities)
• From April 2008 to May 2009, the Department of healthcare Policy and Financing (HCPF), which administers Medicaid for Colorado, generated a list of Medicaid beneficiaries who were eligible for the intervention, but not yet included in the study. The evaluation team randomly assigned 70% of individuals on the list to the intervention group and 30% to the control group.
• Medicaid claims and encounter data for all participants were obtained from the state and the managed care organization. Specifically, HCPF provided Medicaid claims data (April 2007 to May 2011) as the data source for eligible beneficiaries with information on the use of services for the entire sample prior to random assignment and for individuals who remained in FFS Medicaid following random assignment. For individuals in the managed care plan, data on healthcare use came from the managed care plan until the end of February 2010, at which point it came from HCPF

Results

• The care management intervention described in this study was intended to improve the quality of care for Colorado Medicaid’s highest needs and highest cost clients by supporting the patients and PCPs. The care managers were prepared to guide the patients on medical care, as well as social services
• There were barriers to implementing the intervention because care managers had difficulty locating and engaging individuals in services. About 18% had at least 1 hospitalization and 43% had at least one ED visit in the year prior to the intervention. The intervention lasted 2 years and did not result in fewer hospital stays or ED visits for the intervention group
• Although this intervention was designed according to best practices at the time it began, it did not have many of the features of the most effective coordinated care programs. In the Medicare Care Coordination Demonstration, a comparison of programs that reduced hospital admissions and healthcare costs to others indicated that the most effective programs tended to have 6 structural and operational components: 1) They targeted patients at substantial risk of hospitalization; 2) They averaged nearly one in-person contact per month; 3) They had timely access on hospital admissions and ED use to provide transitional care; 4) Care managers interacted closely with primary care providers; 5) They developed care plans, coached patients on managing their conditions, and provided social supports; and 6) They relied primarily on nurses. However, the design of this intervention called for infrequent contact between care managers and patients, and care managers carried extremely high caseloads. It could be interpreted that the lack of significant findings in this study may partly be due to the intervention that was not effectively designed

Key takeaways/implications

• The findings from this study do suggest some lessons for providing care management to a high-needs population such as blind and/or disabled Medicaid beneficiaries. For example, future projects should consider structuring the intervention so that care managers have closer ties to the healthcare providers and the healthcare system to help with patient’s care coordination. Although this program initially stationed some care managers in high-volume clinics, this aspect of the intervention ended early and most services were provided by telephone
• Recent studies on telephone-based care coordination also suggest that specifically targeting individuals may be more effective. Given that in-person contact between care managers and patients would require a higher project cost and may not work for programs that are looking for a cost-effective alternative strategy, previous findings suggest that targeting the right population for the intervention should help to curtail cost