It was fascinating to read about the results of a study just published in the American Journal of Managed Care, and then to interview one of the authors of the study, a physician who was involved in the clinical trial around a care management strategy examined in the study.
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.”
The researchers studied outcomes from a program designed to identify patients at risk for poor outcomes and unnecessary spending, as well as those most likely to benefit from complex care management. The criteria drew from analyses suggesting that combining predictive models, historical claims, and clinician judgment is the most effective approach to identifying patients for complex care management. As the researchers noted, eligible patients for the study were among the top 5 percent of total medical expenditures in the prior 12 months, or were among the top 5 percent of patients on the Chronic Illness Intensity Index score, or were identified via team member nomination. What’s more, once risk-stratified based on those criteria, patients studied “were then required to meet at least 1 of the following criteria: 2 or more inpatient (IP) admissions in the prior 12 months, 3 or more emergency department (ED) visits in the prior 12 months, or 2 or more chronic conditions.” In other words, these were Medicaid patients who were very high utilizers and at considerable risk of poor outcomes.
The program launched on March 1, 2017, and ran until February 28, 2018, at which point patients returned to usual care. One of the absolutely key elements was the incorporation of a community health worker, who was connected with a primary care physician and a social worker, as the core nucleus of the complex care management aspect of the program, along with physician assistants, nurses, and nurse care and case managers, in the clinic setting, as the overall care team.
Conclusions with important implications for diverse patient populations
The researchers, in their section on conclusions, noted that, “Taken together, the results of this study have several important implications for the design and implementation of complex care management programs for high-need, high-cost patients.” Among them, “These findings add to an emerging evidence base suggesting that carefully designed and targeted care management programs can reduce spending and utilization in Medicaid populations. The magnitude of utilization and spending reductions observed in this study were similar to those reported in recent evaluations of complex care management and CHW programs for Medicaid populations, and substantially larger than those reported from programs targeting Medicare patients. Although additional evaluations of programs targeting both populations are needed, these findings suggest that high-need, high-cost Medicaid patients may be better suited for complex care management.”
What’s more, the researchers found that “precise patient targeting is extremely important, in order to maximize the use of available human and other resources to focus on those patients who might benefit the most from these kinds of interventions. Importantly, telephonic outreach failed, with 40 percent of patients randomized to complex care management unable to be reached by phone. And, the authors noted, “[T]he design and implementation of the program incorporated attributes of successful complex care management programs in other populations,” including, among others, “identifying patients at high risk of poor outcomes and avoidable spending; conducting comprehensive assessments of medical, social, and behavioral risk; care planning and routine follow-up; interdisciplinary, team-based care; and the use of CHWs to engage and activate patients, build trust, and better understand and manage the nonmedical drivers of poor outcomes.”
When I interviewed him by phone, Farhad Modarai, D.O. confirmed all of these findings for me, and added depth to them through his perspectives. “[W]e 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,” he told me. “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.”
As Dr. Modarai emphasized, “[T]here’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.”
An additional element of great importance, Modarai told me, was “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.”
In other words, a very high-touch, close-connection approach to care management, facilitated by a data-intensive approach to determining which patients are best suited to complex care management, will be the key. What’s more, if this approach can work with Medicaid populations, it can work with any kind of population.
In short, the findings of this study are quite significant, and the model created by the CareMore clinician and care management leaders is one that should be studied closely by leaders at patient care organizations nationwide. This looks to me like a major breakthrough, and one whose implications are important for U.S. healthcare delivery more broadly.
