Economic Outcomes of Insurer-Led Care Management for High-Cost Medicaid Patients – AJMC.com Managed Markets Network

ABSTRACT

Objectives: To evaluate the impact of the Community-Based Care Management (CBCM) program on total costs of care and utilization among adult high-need, high-cost patients enrolled in a Medicaid managed care organization (MCO). CBCM was a Medicaid insurer-led care coordination and disease management program staffed by nurse care managers paired with community health workers.

Study Design: Retrospective cohort analysis.

Methods: We obtained deidentified health plan claims data, enrollment information, and the MCO’s monthly registry of the top 10% of costliest patients. The analysis included 896 patients enrolled in CBCM over the course of 2 years (January 2016 to December 2017) and a propensity score–matched cohort of high-cost patients (n = 2152) who received primary care at sites that did not participate in CBCM during the same time period. The primary outcomes were total costs of care and utilization in the 12-month period after enrollment. Secondary outcomes included utilization by care setting: outpatient, inpatient, emergency department, pharmacy, postacute care, and all other remaining sites. We used zero-inflated gamma and Poisson regression models to estimate average differences in postperiod costs and utilization between CBCM enrollees versus non-CBCM enrollees.

Results: We did not observe meaningful differences in total costs or visit frequency among CBCM enrollees relative to non-CBCM enrollees.

Conclusions: Although our study found no association between the CBCM program and subsequent cost or utilization outcomes, understanding why these outcomes were not achieved will inform how future Medicaid programs are designed to achieve better patient outcomes and lower costs.

Am J Manag Care. 2020;26(7):In Press

Takeaway Points

• We evaluated the impact of an insurer-led care management and community health worker program in Philadelphia, Pennsylvania, on total costs of care and utilization among high-cost, high-need patients enrolled in a Medicaid managed care organization.
• We did not observe clinically meaningful differences in total costs, visit frequency, or costs by site of care among patients enrolled in the care management program relative to a matched cohort of high-cost patients not enrolled in the program.
• Understanding the reasons that intended cost outcomes were not achieved will inform how Medicaid plans may design future programs intended to improve patient outcomes while controlling costs.

High-need, high-cost patients account for 50% of US health care spending.¹ Fittingly, insurers and health care provider organizations across the country are seeking solutions to improve clinical outcomes while reducing costs for this population.^2,3 High-need, high-cost patients often have multiple chronic conditions,⁴ resulting in medically complex management decisions and hampering the effectiveness of single disease–based programs designed to address their health needs and costs. In addition, they are often burdened by substantial economic and social barriers such as unstable housing, food insecurity, and poverty, which complicate the long-term management of their health.^5,6

Care management programs are commonly proposed as solutions for high-need, high-cost patients. Care management is typically delivered by a nurse or social worker who serves as a bridge between the patient and the clinical care team, the health system, and community resources, while assisting with administrative and care coordination tasks.^7,8 The majority of care management programs are disease specific, focusing on medication adherence and monitoring, disease-specific management, health education, and self-care instructions.^7,9

Care management programs have had mixed results. Alone, disease-specific care management programs supporting existing health care delivery modalities have had minimal to no impact on reducing health care utilization or total costs of care across a variety of clinical settings for a variety of chronic conditions, including congestive heart failure, dementia, and cancer.^7,9

However, when care managers have been paired with community health workers (CHWs), better clinical outcomes and decreased utilization have been observed. The evidence is particularly strong for patients with diabetes.^10-12 CHWs are trusted laypeople, often from the local community, hired and trained to support patients. CHWs perform various roles, including informal social support, coaching to improve health behaviors, navigating complex health systems, coordinating care, and patient advocacy. CHW interventions are increasingly common and have, even independent of being paired with care managers, improved chronic disease outcomes.^13-17 Many CHW programs are disease specific¹⁶ and face challenges scaling across institutions.^18,19 More recent evidence indicates that CHWs who manage patients with 2 or more chronic conditions and significant social needs can reduce hospital admission days by 65%.²⁰

Despite the promise, the impact of care managers teamed with CHWs to manage a broad set of clinical and social needs for high-need, high-cost patients is understudied.²¹ We sought to fill this knowledge gap by evaluating the impact of a Medicaid insurer-led care management and CHW program on economic measures—total costs of care and utilization—in Philadelphia, Pennsylvania, a racially diverse city with the fifth-largest population and the highest poverty rate among the 10 largest cities in the United States.²²

METHODS

This study is a retrospective, claims-based analysis of total costs of care and health care utilization among adult high-need, high-cost patients enrolled in Community-Based Care Management (CBCM), a care coordination and disease management program staffed by teams of nurse care managers paired with CHWs. CBCM was developed in partnership between a southeast Pennsylvania Medicaid managed care organization (MCO) and multiple health care provider organizations in North and West Philadelphia, some of the poorest neighborhoods in the city. In addition to intensive care management from the nurse and the CHW, CBCM enrollees received dedicated social work from some of the practices, and all CBCM care managers and CHWs received administrative support from dedicated project and medical directors.

The primary analysis compares total costs of care and utilization after CBCM enrollees enter the program with a propensity score–matched cohort of high-need, high-cost patients who were not offered CBCM because they received care at primary care practices without embedded teams. The 24-month study period is between January 2016 and December 2017. This study was approved by the institutional review board at the University of Pennsylvania.