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Policy Framework
Despite skyrocketing health care spending, many people in the U.S. do not receive the health care they need. In addition to the tens of millions of Americans who lack health insurance, those with insurance often get inadequate care because the fractured American health care system makes it difficult for individuals to make appropriate health care choices. Lack of adequate care is of particular concern for individuals with chronic health conditions, who may suffer deteriorating health while driving up health care costs if they make poor use of the health care system.
To help individuals make better health care choices, many health care systems have turned to care management, which can include a range of activities to help individuals make appropriate health care choices and manage their health conditions. Care managers can refer patients to the right doctors, help them make and keep appointments, and help them comply with medical or dietary recommendations. Coordinated care programs also work directly with health care providers to ensure that someone is looking after the patient’s needs, while helping to avoid unnecessary or duplicative care.
Although a fair amount of research indicates that care management is effective for particular diseases (such as depression), public health systems, including Medicaid and Medicare, have only recently begun using care management, and there is little evidence that care management is effective for high-needs Medicaid recipients. To help fill this knowledge gap, MDRC is partnering with the Center for Health Care Strategies (CHCS) to evaluate care management programs for high-needs Medicaid recipients.
Agenda, Scope, and Goals
The goal of the study is to identify states that are about to launch coordinated care initiatives for high-cost Medicaid recipients with disabilities and that are interested in rigorous studies of those programs. In particular, MDRC is hoping to use random assignment to evaluate these programs in order to determine whether they meet their goals of improving the quality of health care and reduce its cost by helping individuals make more appropriate health care choices and by coordinating care across health care providers. These evaluations will be the first large-scale, rigorous studies of coordinated care for high-needs Medicaid recipients that we know of. They will provide crucial information to state, local, and national policymakers about whether such interventions are effective at increasing the quality of care and reducing health care costs. At the national level, some policymakers see successful cost containment as a necessary precursor to any serious effort to enact national health insurance. At the state level, cost containment for high-cost cases has become a leading priority for state Medicaid programs.
Design, Sites, and Data Sources
MDRC has begun an evaluation of a coordinated care program in Colorado and is discussing the possibility of an evaluation in New York.
Colorado. The evaluation in Colorado is currently taking place in four counties: Adams, Arapahoe, Boulder, and Weld. The evaluation might be extended to additional counties and service providers in the future. In these counties, Colorado Access has developed a coordinated care model that is similar to one they currently use with high-needs Medicare patients and stems from extensive experience providing health care services to underserved groups, as well as their own rigorous research on effective care management.
Care managers, who will work with patients by telephone or in selected locations in the community (such as high-volume health care providers), will assess each individual’s health care needs in order to develop individualized care plans. A patient whose care needs seem to be well managed will receive limited care management, while one who is struggling with multiple chronic conditions will receive more intensive care management. For example, a diabetic patient with pulmonary disease and a substance abuse problem might be contacted by a care manager several times a week to assess the person’s medical needs, help them make appointments to see appropriate health care providers, and monitor their compliance with recommended actions, such as taking medications, following an appropriate diet, and checking blood sugar levels. The care manager would also try to work with the patient’s primary care physician to make sure someone is coordinating care across the variety of specialists that the patient is likely to see. Although protocols would provide care managers with suggestions for what is appropriate care, the care managers will have substantial discretion to do what is necessary to help patients receive high-quality, appropriate care.
The evaluation of this program is building off of a state plan to phase in the Colorado Access program in six counties. In 2008, a randomly chosen portion of eligible Medicaid patients who are currently in the fee-for-service system will be sent a letter saying they have been enrolled in the Colorado Access managed care program and telling them how they can opt out of the program. The remainder will remain in fee-for-service care for at least another two years. Because the group that is passively enrolled in the Colorado Access program in 2008 is being chosen at random, any differences that emerge in health care and health outcomes between the two groups over the following two years can be reliably attributed to the Colorado Access program.
New York. In New York, the state legislature approved $10 million to fund the Chronic Illness Demonstration Project (CIDP), which will provide coordinated care for high-needs Medicaid beneficiaries with multiple chronic conditions in New York’s fee-for-service Medicaid system. It is anticipated that five to seven demonstrations will be funded under CIDP. In collaboration with CHCS, MDRC has had discussions with the state about evaluating the programs, but evaluation plans have not been finalized.
In both states, the core of the evaluation will be an impact study that will use state administrative records to examine the effects of care management on health care choices and health care costs. Surveys of participants might also be used to collect information on health outcomes and to learn about their perceptions of care management and satisfaction with the health care system. An implementation study will explore how care management differs from place to place to help gain an understanding of what makes such programs effective. Finally, a cost-benefit study will investigate whether care management can be used to save government funds while improving individuals’ health outcomes.
What's Next
Random assignment is taking place now in Colorado. The New York Department of Health is now choosing sites for CIDP. The studies are expected to continue until 2012.
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