On February 10, the American Journal of Managed Care published an article that provided a new perspective on complex care management among Medicaid patients. “Impact of Complex Care Management on Spending and Utilization for High-Need, High-Cost Medicaid Patients” was written by Brian W. Powers, M.D.; Farhad Modarai, D.O.; Sandeep Palakodeti, M.D., M.P.H.; Manisha Sharma, M.D.; Nupur Mehta, M.D.; Sachin H. Jain, M.D.; and Vivek Garg, M.D.
As the authors note in the introduction to their article, “Complex care management programs have emerged as a promising model to better care for high-need, high-cost patients. Despite their widespread use, relatively little is known about the impact of these programs in Medicaid populations. This study evaluated the impact of a complex care management program on spending and utilization for high-need, high-cost Medicaid patients.”
For their study, the researchers conducted a randomized quality improvement trial at CareMore Health in Memphis, Tennessee. CareMore Health, a subsidiary of the Indianapolis-based Anthem, Inc., is a physician-led integrated health system. The researchers examined the outcomes for 253 high-need, high-cost Medicaid patients randomized in a 1:2 ratio to complex care management versus usual care. CareMore Health is a healthcare delivery system that began in Memphis and now serves 160,000 Medicaid patients in nine states and the District of Columbia.
What did the researchers find? They found that, compared to the control group, patients randomized to complex care management had lower costs ($7,732 lower per member per year, and 37 percent lower overall medical expenditures per year), fewer inpatient days (3.46 fewer inpatient days per member per year, and 59 percent lower inpatient utilization per year), fewer inpatient admissions (0.32 fewer inpatient admissions per member per year), and fewer specialist visits (1.35 fewer specialist visits per member per year). The conclusion? “Carefully designed and targeted complex care management programs may be an effective approach to caring for high-need, high-cost Medicaid patients.”
Shortly after the publication of the research study in the American Journal of Managed Care, Farhad Modarai, D.O., one of the study’s leaders and one of the co-authors of the article, spoke with Healthcare Innovation Editor-in-Chief Mark Hagland regarding the findings of the study and what’s been learned from it. Dr. Modarai was one of the key physician leaders involved in the complex care management process in the Memphis CareMore clinics. Below are excerpts from that interview.
How long have you been in clinical practice?
I finished my family practice residency four-and-a-half years ago. This work was done in Memphis, and that’s where I was. Now with CareMore, we’re entering into the North Carolina market to launch our care management model here, in Raleigh-Durham.
What study data and conclusions did you find to be the most significant?
We were comparing ourselves to ourselves: we had a wraparound transitions of care/case management and longitudinal primary care case management embedded into our program already. Our case management programs were really tailored and designed for Medicare Advantage patients, and now that we’ve entered into caring for complex Medicaid patients—we’re a fully capitated Medicaid model in Tennessee. That was CareMore’s first time caring for a Medicaid population, and there was a lot more social complexity in caring for that population.
With regard to learning from all the programs under way, we realized that a community health worker might be appropriate to embed into the team; and having a meaningful and purposeful embedding of behavioral health would be important. And I was a primary care physician involved, and our model included intentionally involving the PCP in collaborating every day in daily rounds with the team, which involved a social worker, community health worker, and medical assistants, all huddling together. The core of the intervention team, for the patients being studied for outcomes from intervention, was a PCP, a community health worker, and a social worker, with a wraparound in the clinics of medical assistants, care managers, and nurse case managers.
And there are a lot of core principles involved. But our [line of analysis] came down to, did we identify the right patients, and engage them successfully, in terms of our high touch and responsive care approaches? And comparing ourselves to ourselves, we found that we were able to bend the cost curve for these patients, so it was rewarding to see, and really being able to highlight cases like that.
Identifying the right patients, engaging them successfully, and interacting with the multidisciplinary care team—can you drill down on those elements?
Sure. Per the first, in terms of the literature, we realized we weren’t necessarily going to find the right patients just by looking through historical claims data. So we combined a quantitative and qualitative approach to identify patients. We also heavily anchored on intuition and clinician judgment. And we used the EHR [electronic health record], utilized predictive risks cores through an algorithm. So we had a quantitative approach, but also a qualitative approach. And any staff member could refer a patient if they saw medical or social complexity. That was our way of marrying a quantitative and qualitive approach.
Per the second part, engagement, we took engagement very seriously. We understood something about our population: if you are a Medicaid patient and are living in poverty in Memphis, there is a lot of inherent distrust of the medical establishment and processes. So how we talk to a patient in order to garner their trust, to get them to buy into what we’re trying to offer—there’s a lot involved there. So we approached all of this through a harm reduction lens, and also trying to meet patients where they were at. And we got daily census data from the ED and the hospital, and sometimes, the first encounter might be engaging them at the bedside, where we would do a comprehensive assessment and care plan. So there’s a lot of intentionality around creating the care plan. Then, how do we make sure we’re following through on commitments, and are project-managing every aspect of the patient’s care, every step of the way, and trying to help the patient take own ownership. So we employed a coaching model, to meet patients where they were at.
And the daily meeting of the team—we had a very small panel size relative to primary care panels. This was a handful of patients in the intervention arm. These were all fairly high-risk patients. And our community health worker, the patients were trained to give her a call if anything came up. And she and I were working together day in and day out. We had a patient who called and said hey, I ran out of my insulin, and the pharmacy didn’t have any. That typically would be routed to the PCP, who would have 72 hours to turn that around, whereas, I was sitting right there, we had an insulin problem, and I could turn that around within an hour. Those little things can be taken for granted, but complex case management programs that aren’t embedded in the care delivery might not be able to address such things. That plays a big role.
Were there any surprises in the study’s findings.
There were a few. We didn’t see a change in ED visits, which was interesting. We didn’t see an impact on ED visits, but inpatient lengths of stay were decreased, and specialist visits were decreased, and we think we didn’t rely on specialists quite as much as in the typical care model. When you’re working with a smaller panel, you can have a broader view of the patient and probably not rely quite as much on specialists.
Can you tell me about the data analytics and IT that you leveraged in order to support this?
That is a big strength within our organization: we have a lot of data analytical support. We have various predictive models we’re able to deploy; we have a really robust population health dashboard, and I can see every claim, every prescription, every ED visit, for every patient. We have various ways in which we do segmentation analysis on our population, in order to bucket levels of risk. Our data analytics capabilities within CareMore in general, are pretty strong.
What are the top pieces of advice that you’d like to share, regarding your team’s experience here?
I think the biggest thing is, don’t be afraid to be vulnerable with patients, to gain their trust. Often in healthcare, we feel we have to put on such a professional lens, but so often, patients just respond to you being a human being, and to your following through on commitments. That will get you so much further than any fancy program or analytics. So just train the team to be OK with venturing out into the unknown with the patient. We focused a lot on in-person trust-building versus telephonic, and that was a big difference between our program and those case management programs that rely on telephonic case management. Telephonic works after you’ve built trust, but starting with initial telephonic case management isn’t as strong.
If we couldn’t find a patient, we would knock on the door on the most recent address we had. So don’t be afraid to just step out into the community.