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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 with disabilities.
Design, Sites, and Data Sources
MDRC is currently conducting evaluation of coordinated care programs in Colorado and New York.
Colorado. The evaluation in Colorado is currently taking place in six counties: Adams, Arapahoe, Boulder, Weld, Denver, and Jefferson. In these counties, two versions of coordinated care are being tested, with services provided by Colorado Access or Kaiser Permanente.
Both organizations have developed coordinated care programs that are similar to ones they have used with high-needs Medicare patients. Each program has several goals. One is to reduce the use of Emergency Departments for routine care by establishing a primary care provider for each patient and helping the patient make and keep appointments. A second is to help patients comply with treatment recommendations — such as taking medications, making follow-up appointments, and eating well — to keep chronic conditions from worsening to the point where hospitalizations are needed. Care managers will begin by assessing each individual’s health care and social service 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 coordinated care. In 2008, a randomly chosen portion of eligible Medicaid patients in Adams, Arapahoe, Boulder, and Weld counties who are currently in the fee-for-service system were sent a letter saying they had been enrolled in the Colorado Access managed care program and telling them how they could opt out of the program. The remainder will remain in fee-for-service care for at least two years from the date of random assignment. Because the group that was passively enrolled in the Colorado Access program was 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. In 2009, a similar process began for the Kaiser Permanente pilot. Random assignment has now ended for both pilots, and services for the Colorado Access pilot have now ended.
New York. In New York, the state legislature approved funding for 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. In January 2009, the state announced that six programs had been funded, three in New York City, and one each in Nassau, Westchester, and Erie (Buffalo) Counties. Programs began operations in summer 2009.
Individuals are eligible for CIDP services if they are currently receiving fee-for-service Medicaid and are likely to be hospitalized in the coming year according to a predictive model developed by John Billings at New York University. This is a high-needs group. On average, they are hospitalized about three times a year and use nearly $60,000 per year in Medicaid benefits. About three-quarters have been diagnosed with a mental illness and four-fifths have been diagnosed with a substance abuse problem. They also suffer from a range of other chronic conditions. Increasing primary care and reducing emergency department and hospital use for this group may result in substantial savings to the health care system.
The evaluations. 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.
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 aspect of 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.
What's Next
Claims data are being analyzed in both states to see whether the pilot programs have made a difference. Implementation research is ongoing in both states to understand how the programs were implemented and differences across programs. The studies are expected to continue until 2013, when final reports will be released.
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