Evaluation of a National Care Coordination Program to Reduce Utilization Among High-cost, High-need Medicaid Beneficiaries With Diabetes

Abstract

Background: Medical, behavioral, and social determinants of health are each associated with high levels of emergency department (ED) visits and hospitalizations. Objective: The objective of this study was to evaluate a care coordination program designed to provide combined “whole-person care,” integrating medical, behavioral, and social support for high-cost, high-need Medicaid beneficiaries by targeting access barriers and social determinants. Research Design: Individual-level interrupted time series with a comparator group, using person-month as the unit of analysis. Subjects: A total of 42,214 UnitedHealthcare Medicaid beneficiaries (194,834 person-months) age 21 years or above with diabetes, with Temporary Assistance to Needy Families, Medicaid expansion, Supplemental Security Income without Medicare, or dual Medicaid/Medicare. Measures: Our outcome measures were any hospitalizations and any ED visits in a given month. Covariates of interest included an indicator for intervention versus comparator group and indicator and spline variables measuring changes in an outcome’s time trend after program enrollment. Results: Overall, 6 of the 8 examined comparisons were not statistically significant. Among Supplemental Security Income beneficiaries, we observed a larger projected decrease in ED visit risk among the intervention sample versus the comparator sample at 12 months postenrollment (difference-in-difference: −6.6%; 95% confidence interval: −11.2%, −2.1%). Among expansion beneficiaries, we observed a greater decrease in hospitalization risk among the intervention sample versus the comparator sample at 12 months postenrollment (difference-in-difference: −5.8%; 95% confidence interval: −11.4%, −0.2%). Conclusion: A care coordination program designed to reduce utilization among high-cost, high-need Medicaid beneficiaries was associated with fewer ED visits and hospitalizations for patients with diabetes in selected Medicaid programs but not others.

High-cost high-need patients in Medicaid: segmenting the population eligible for a national complex case management program

“…Once administrators disaggregate stable subgroups, the next step is to tailor complex case management to the unique clinical needs of the subgroup. There has been substantial work done in this area in Medicaid, including outpatient extensivist teams for patients with behavioral health conditions [ 30 ], qualitative work addressing the needs of pregnant women utilizing unscheduled care [ 31 ], disease-focused complex case management [ 19 ], and more intensive home-based interventions utilizing community health workers [ 18 , 32 ]. Finally, the increasing availability of national systematic samples may facilitate developing a generalizable model of high-cost high-need patient subgroups in Medicaid which would speed the development of tools to identify patients appropriate for complex case management or other intervention strategies.…”

“…The objective of our study is to disaggregate or segment a multi-state sample of high-cost high-need Medicaid patients who were eligible for a national complex case management program led by UnitedHealthcare to address medical, behavioral, and unmet social needs through a phone-based RN-led complex case management intervention, which was evaluated previously by our research team and found to be ineffective at reducing hospitalizations or emergency room visits in most Medicaid beneficiaries [ 19 ].…”

Primary Care Practice Structural Capabilities and Emergency Department Utilization Among High-Need High-Cost Patients

“…However, recent studies indicate that the impact of care coordination differs across the HNHC population when measuring hospitalization rate, ED utilization, and total costs of care R. S. Brown et al, 2012;Duru et al, 2020). For example, Brown et al found care coordination reduced hospitalizations only when directed at HNHC patients with a higher-risk of being hospitalized.…”

“…However, in order to develop targeted interventions, research is first needed to identify best approaches to segmenting HNHC patients with wide-ranging needs. Future research should specifically evaluate existing strategies such as subgrouping HNHC patients by specific comorbidities and spending patterns, socioeconomic needs, or risk for hospitalization (R. S. Duru et al, 2020;.…”

“…Care coordination, for example, consists of the integration of personnel or activities used to manage patient care across the health care spectrum. Among HNHC patients, care coordination has been shown to be associated with fewer hospitalizations and ED visits (Duru et al, 2020) and to lower per beneficiary episode costs by $4,295 . Effective care coordination is critical for HNHC patients as fragmented care across settings and between specialists is associated with increased rates of preventable hospitalizations and costs of care .…”