Often in healthcare, it’s very important to be able to document information and insights that experts and leaders already knew before the research was done. That certainly seems to apply in this instance, in which a study has been published in the July issue of the American Journal of Managed Care that confirms that complex care management is having a significant positive impact on both clinical and financial outcomes in accountable care organizations participating in the Next Generation (Next Gen) ACO program. Indeed, the study has found that complex care management has resulted in a 21-percent reduction in hospitalizations and a 22-percent reduction in costs. And yes, that’s very meaningful, particularly given how difficult it is to change the dynamics of care and cost in patient care delivery.
The article, entitled “Effective Care Management by next Generation Accountable Care Organizations,” was written by Neal O’Hara, Olivia c. Tran, Shantanu Phatakwala, Anita Cattrell, Ph.D., and Youssef Ajami. Those researchers looked at outcomes with regard to “the utilization and spending impact of a standardized complex care management program implemented at 5 Next Generation accountable care organizations (NGACOs) and to identify reproducible program features that influenced program effectiveness.” Their study design? “In 2016 and 2017, high-risk Medicare beneficiaries aligned to 5 geographically diverse NGACOs were identified using predictive analytics for enrollment in a standardized complex care management program.”
And, in examining the impact of complex care management in the Next Gen program on “all-cause inpatient admissions, emergency department visits, and total medical expenditures (TME) relative to a matched cohort of nonparticipants,” they found that “Program participation was associated with a 21-percent reduction in all-cause inpatient admissions (P = .03) and a 22-percent reduction in TME (P = .02) 6 months after program completion. Relative spending reductions were 2.1 times greater for high-fidelity interventions compared with overall program participation (P < .001).” As a result, they conclude, “Centrally staffed complex care management programs can reduce costs and improve outcomes for high-risk Medicare beneficiaries. Integrating predictive risk stratification, evidence-based intervention design, and performance monitoring can ensure consistent outcomes.”
Among the key findings:
Program participation was significantly associated with reduced all-cause inpatient admissions (–21.2 percent) and lower total medical expenditures (–22.0 percent) compared with a propensity score–matched cohort of nonparticipants.
The researchers identified specific program features that were significantly associated with intervention fidelity.
Relative spending reductions were 1.9 times greater for high-fidelity interventions compared with overall program participation.
Future accountable care organization leaders can use these findings to inform effective care management program design.
This is quite significant, really, given the built-in challenges in the ACO programs. What’s more, it’s fascinating to consider both how significant the complex care management interventions were, and the fact that reductions in all-cause inpatient admissions (21 percent) and total medical expenditures (22 percent) were virtually identical in impact. In other words, the interventions had equally strong impacts both financially and clinically. And, as noted above, it was the intensive interventions that really made a big difference.
I’m finding all of this to be very heartening, particularly at this inflection point in the evolution of value-based care delivery and payment in U.S. healthcare, as Seema Verma and other officials at the Centers for Medicare & Medicaid Services (CMS) continue to urge provider leaders forward towards value-based, including risk-based, contracting, even in the middle of the current COVID-19 pandemic. It’s important that there be documentation of the actual progress being made by ACO leaders and by the leaders of all patient care organizations that have been participating in risk-based and any value-based contracts.
And the specifics are even more impressive than the overview. Describing the program involved, the researchers write that, “In 2016 and 2017, Evolent Health, a provider of value-based care services, partnered with 5 NGACOs to implement a complex care management program targeted at Medicare beneficiaries with chronic comorbidities and a high risk of hospitalization.13 In the program, registered nurses led an evidence-driven, team-based care advising approach9,18-22 aimed at reducing hospitalizations, ED visits, and TME among participating beneficiaries. Common chronic conditions within the target population included chronic obstructive pulmonary disease, coronary artery disease, diabetes, congestive heart failure, and asthma. Some patients also exhibited comorbid diagnoses with chronic kidney disease, behavioral health conditions, or neurocognitive disorders.”
In that context, they note, “Nearly 87 percent of program participants were proactively identified via predictive risk stratification. Machine learning models predicted each patient’s risk of incurring a future avoidable hospitalization using administrative, clinical, and sociodemographic variables such as comorbid diagnoses, condition severity, acute utilization trends, laboratory values, educational attainment, and food access. A small subset of enrollees (13%) were referred to the program by their physician. Once identified, patients were added to a queue for telephonic outreach from a registered nurse. Program coordinators prioritized patients for outreach according to predicted admission risk, along with the output from a separate predictive model that estimated each prospective participant’s likelihood of enrolling in the program.25 Across all ACOs during the study period, approximately 3% of patients were identified as appropriate for the program.”
In terms of the program design, the authors write, “Registered nurses collaborated with patients, their physicians, and an extended care team to develop an individualized care plan focused on six key mechanisms: barrier identification and action planning, gap in care closure, care coordination, basic medication reconciliation, patient activation and education, and referrals to local or electronic resources. Program duration averaged 4 months, and patient-care advising interactions were designed to occur at least every 14 calendar days. More than 96 percent of patient-care advising interactions occurred telephonically,” they note. “Patients graduated from the program once all identified barriers were resolved. A web-based care management workflow tool was used to document all program activities, monitor key performance indicators, trigger relevant clinical alerts, and identify patients due for follow-up. Program coordinators periodically reviewed aggregate performance data each month to identify best practices and develop process improvement plans.”
And while none of these details are surprising, the fact that this program has involved such intensive, continuous interaction between care managers and patients, with great detail and planfulness, speaks to the absolute key that is the intensity involved here.
So I very much hope that this study is seriously considered by CMS officials and all other stakeholder group leaders, going forward; because it speaks to the core elements that will be needed not only to ensure the success of accountable care in the formal sense, but really, care delivery more broadly, in the emerging healthcare system both in the face of the COVID-19 challenge, and what is to come afterwards. Intensive care coordination is the future of healthcare—and this study proves it in rigorous detail.
