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

Social Risks and Health Care Use in Medically Complex Patients

Importance

Integrated health care systems have initiated major investments to identify and address social risks, particularly for patients with multiple medical conditions.

Objective

To evaluate the association of social risks with health care use among patients with complex multimorbidity.

Design, Setting, and Participants

This longitudinal cohort study assessed Kaiser Permanente Northern California (KPNC) patients with (1) moderate medical complexity (defined by high comorbidity score, high risk of hospitalization, and/or prior emergency department [ED] admissions) and (2) high medical complexity (eg, meeting additional criteria, such as ≥7 medications and laboratory evidence of poor disease control).

Exposure

Social risks (eg, requiring medical financial assistance and self-reported social barriers to care).

Main Outcomes and Measures

Inpatient and outpatient health care use during 12 months of follow-up (January 15, 2023, to January 14, 2024).

Results

The sample included 97 252 KPNC patients (mean [SD] age, 69.5 [16] years; 52.1% female; 10.6% Asian, 11.1% Black, 18.3% Hispanic, 54.6% White, and 5.5% other race or ethnicity [eg, American Indian or Alaskan Native, Native Hawaiian or Pacific Islander, multiracial, or unknown race]; and 8.8% insured by Medicaid), including 27 827 with moderate medical complexity (5074 [18.2%] with social risks) and 69 425 with high medical complexity (17 343 [25.0%] with social risks). In fully adjusted models, for moderate medical complexity, social risks were associated with higher odds of inpatient admissions (odds ratio [OR], 1.2; 95% CI, 1.1-1.4), ED visits (OR, 1.2; 95% CI, 1.1-1.3), and mental health visits (OR, 1.2; 95% CI, 1.1-1.3) vs individuals without social risks. Among individuals with high medical complexity, social risks were associated with higher odds of inpatient admissions (OR, 1.2; 95% CI, 1.1-1.2), ED visits (OR, 1.2; 95% CI, 1.1-1.2), and 30-day readmissions (OR, 1.2; 95% CI, 1.1-1.3) and higher odds of mental health visits (OR, 1.3; 95% CI, 1.2-1.3) vs individuals without social risks.

Conclusions and relevance

In this cohort study of individuals with medical complexity, coexisting social risks were associated with substantial downstream health care use. Efforts to reduce use in individuals with complex medical comorbidity could include concurrent efforts to identify and reduce social risks.

Impact of Referring High-Risk Patients to Intensive Outpatient Primary Care Services: A Propensity Score-Matched Analysis

BACKGROUND

Many healthcare systems have implemented intensive outpatient primary care programs with the hopes of reducing healthcare costs.

OBJECTIVE

The Veterans Health Administration (VHA) piloted primary care intensive management (PIM) for patients at high risk for hospitalization or death, or "high-risk." We evaluated whether a referral model would decrease high-risk patient costs.

DESIGN

Retrospective cohort study using a quasi-experimental design comparing 456 high-risk patients referred to PIM from October 2017 to September 2018 to 415 high-risk patients matched on propensity score.

PARTICIPANTS

Veterans in the top 10th percentile of risk for 90-day hospitalization or death and recent hospitalization or emergency department (ED) visit.

INTERVENTION

PIM consisted of interdisciplinary teams that performed comprehensive assessments, intensive case management, and care coordination services.

MAIN OUTCOMES AND MEASURES

Change in VHA and non-VHA outpatient utilization, inpatient admissions, and costs 12 months pre- and post-index date.

KEY RESULTS

Of the 456 patients referred to PIM, 301 (66%) enrolled. High-risk patients referred to PIM had a marginal reduction in ED visits (- 0.7; [95% CI - 1.50 to 0.08]; p = 0.08) compared to propensity-matched high-risk patients; overall outpatient costs were similar. High-risk patients referred to PIM had similar number of medical/surgical hospitalizations (- 0.2; [95% CI, - 0.6 to 0.16]; p = 0.2), significant increases in length of stay (6.36; [CI, - 0.01 to 12.72]; p = 0.05), and higher inpatient costs ($22,628, [CI, $3587 to $41,669]; p = 0.02) than those not referred to PIM.

CONCLUSIONS AND RELEVANCE

VHA intensive outpatient primary care was associated with higher costs. Referral to intensive case management programs targets the most complex patients and may lead to increased utilization and costs, particularly in an integrated healthcare setting with robust patient-centered medical homes.

TRIAL REGISTRATION

PIM 2.0: Patient Aligned Care Team (PACT) Intensive Management (PIM) Project (PIM2). NCT04521816. https://clinicaltrials.gov/study/NCT04521816.

Concentration of High-Cost Head and Neck Cancer Surgical Patients

OBJECTIVE

Health care costs are disproportionately concentrated among a small number of patients. We sought to identify variables associated with high-cost patients and high hospital concentration of high-cost patients and to examine associations with short-term outcomes in head and neck cancer (HNCA) surgery.

STUDY DESIGN

The Nationwide Inpatient Sample was used to identify 170,577 patients who underwent HNCA surgery in 2001-2011. High-cost patients were defined as patients whose costs of care were in the top decile, and high-concentration hospitals were defined as those whose percentage of high-cost patients was in the top decile.

METHODS

Multivariable regression was used to evaluate associations between cost and patient and hospital variables, postoperative complications, and in-hospital mortality.

RESULTS

Costs associated with high-cost patients were 4.47-fold greater than the remaining 90% of patients. High-concentration hospitals treated 36% of all high-cost patients. High-cost patients were more likely to be non-white (OR = 2.08 [1.45-2.97]), have oral cavity cancer (OR = 1.21 [1.05-1.39]), advanced comorbidity (OR = 1.53 [1.31-1.77]), Medicaid (OR = 1.93 [1.62-2.31]) or self-pay payor status (OR = 1.72 [1.38-2.14]), income>50th percentile (OR = 1.25 [1.05-1.51]), undergo major procedures (OR = 3.52 [3.07-4.05]) and have non-routine discharge (OR = 7.50 [6.01-9.35]). High-concentration hospitals were more likely to be teaching hospitals (OR = 3.14 [1.64-6.05]) and less likely to be urban (OR = 0.20 [0.04-0.93]). After controlling for all other variables, high-cost patients were associated with an increased odds of mortality (OR = 8.00 [5.89-10.85]) and postoperative complications (OR = 5.88 [5.18-6.68]). High-concentration hospitals were associated with an increased odds of postoperative complications (OR = 1.31 [1.08-1.61]) but were not associated with increased mortality (OR = 0.98 [0.67-1.44]).

CONCLUSIONS

High-cost HNCA surgical patients are associated with increased postoperative morbidity and mortality, and are disproportionately concentrated at teaching hospitals.

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

Does Interdisciplinary Care Team Care Management Improve Health Quality and Demonstrate Cost-Effectiveness?

This study evaluated the impact of an interdisciplinary care teams (IDCT) care management program on cost and quality outcomes using a novel algorithm to identify 400 high-risk patients out of 48,235 Medicare Advantage (MA) beneficiaries. Of the 400, 252 were enrolled in the IDCT care management intervention program, while the remaining 148 were not enrolled. A second comparison group consisted of 660 who were referred to the IDCT program but not selected by the algorithm. The program's effectiveness was evaluated 1-year postintervention. Analyses found that health care costs for members enrolled in the IDCT program were reduced by US$1,121.76 and US$1,625.61 per member per month, respectively, relative to those not enrolled and those enrolled by referral. The cost reduction from the program generated a net savings of US$1.9MM, covering the program's cost. Findings suggest IDCTs can cost-effectively manage populations of high-risk patients with better selection and fostering greater interdependence.

Identifying High-Cost, High-Need Patients in a Network of Community Hospitals

We examined healthcare costs at HonorHealth, a community-based academic health center comprised of 5 hospitals and numerous ambulatory care facilities. Patient encounters that resulted in admission in 2019 were included in the study. Mean costs in 2019 for high costs and high needs (HCHN) patients were compared with all remaining patients using a framework developed by the National Academy of Medicine. HCHN patients were older (71 vs 52 years), with a lower percentage of females (41.7% vs 59.8%), more frequently White (90.1% vs 87.5%), less frequently married (52.4% vs 54.5%), with a longer length of stay (6.5 vs 3.0 days) and higher mean charges ($134 743 vs $16 414). The mean cost per patient in the HCHN group decreased by age group ($192, 963, $165 200, $144 584, $134 795, and $108 356) for 0 to 18, 19 to 44, 45 to 64, 65 to 84, and 85+ years, respectively. HCHN patients were more publicly insured (49% vs 38%). Targeted interventions to treat HCHN may lead to lower healthcare costs and improved health outcomes within this system.

Characterizing hospitalization trajectories in the high-need, high-cost population using electronic health record data

High utilization by a minority of patients accounts for a large share of health care costs, but the dynamics of this utilization remain poorly understood. We sought to characterize longitudinal trajectories of hospitalization among adult patients at an academic medical center from 2017 to 2023. Among 3404 patients meeting eligibility criteria, following an initial "rising-risk" period of 3 hospitalizations in 6 months, growth mixture modeling discerned 4 clusters of subsequent hospitalization trajectories: no further utilization, low chronic utilization, persistently high utilization with a slow rate of increase, and persistently high utilization with a fast rate of increase. Baseline factors associated with higher-order hospitalization trajectories included admission to a nonsurgical service, full code status, intensive care unit-level care, opioid administration, discharge home, and comorbid cardiovascular disease, end-stage kidney or liver disease, or cancer. Characterizing hospitalization trajectories and their correlates in this manner lays groundwork for early identification of those most likely to become high-need, high-cost patients.

Challenges in predicting future high-cost patients for care management interventions

BACKGROUND

To test the accuracy of a segmentation approach using claims data to predict Medicare beneficiaries most likely to be hospitalized in a subsequent year.

METHODS

This article uses a 100-percent sample of Medicare beneficiaries from 2017 to 2018. This analysis is designed to illustrate the actuarial limitations of person-centered risk segmentation by looking at the number and rate of hospitalizations for progressively narrower segments of heart failure patients and a national fee-for-service comparison group. Cohorts are defined using 2017 data and then 2018 hospitalization rates are shown graphically.

RESULTS

As the segments get narrower, the 2018 hospitalization rates increased, but the percentage of total Medicare FFS hospitalizations accounted for went down. In all three segments and the total Medicare FFS population, more than half of all patients did not have a hospitalization in 2018.

CONCLUSIONS

With the difficulty of identifying future high utilizing beneficiaries, health systems should consider the addition of clinician input and 'light touch' monitoring activities to improve the prediction of high-need, high-cost cohorts. It may also be beneficial to develop systemic strategies to manage utilization and steer beneficiaries to efficient providers rather than targeting individual patients.

Differential Impact of a Plan-Led Standardized Complex Care Management Intervention on Subgroups of High-Cost High-Need Medicaid Patients

Interventions to better coordinate care for high-need high-cost (HNHC) Medicaid patients frequently fail to demonstrate changes in hospitalizations or emergency department (ED) use. Many of these interventions are modeled after practice-level complex care management (CCM) programs. The authors hypothesized that a national CCM program may be effective for some subgroups of HNHC patients, and the overall null effect may obfuscate subgroup-level impact. They used a previously published typology defining 6 subgroups of high-cost Medicaid patients and evaluated program impact by subgroup. The analysis used an individual-level interrupted time series with a comparison group. Intervention subjects were high-cost adult Medicaid patients who enrolled in 1 of 2 national CCM programs implemented by UnitedHealthcare (UHC) (n = 39,687). The comparators were patients who met CCM program criteria but were ineligible due to current enrollment in another UHC/Optum led program (N = 26,359). The intervention was a CCM program developed by UHC/Optum to provide "whole person care" delivering standardized interventions to address medical, behavioral, and social needs for HNHC Medicaid patients, and the outcome was probability of hospitalization or ED use in a given month, estimated at 12 months postenrollment. A reduction in risk of ED utilization for 4 of 6 subgroups was found. A reduction in risk of hospitalization for 1 of 6 subgroups was also found. The authors conclude that standardized health plan led CCM programs demonstrate effectiveness for certain subgroups of HNHC patients in Medicaid. This effectiveness is principally in reducing ED risk and may extend to the risk of hospitalization for a small number of patients.

Characteristics of High-Need, High-Cost Patients : A "Best-Fit" Framework Synthesis

BACKGROUND

Accurately identifying high-need, high-cost (HNHC) patients to reduce their preventable or modifiable health care use for their chronic conditions is a priority and a challenge for U.S. policymakers, health care delivery systems, and payers.

PURPOSE

To identify characteristics and criteria to distinguish HNHC patients.

DATA SOURCES

Searches of multiple databases and gray literature from 1 January 2000 to 22 January 2022.

STUDY SELECTION

English-language studies of characteristics and criteria to identify HNHC adult patients, defined as those with high use (emergency department, inpatient, or total services) or high cost.

DATA EXTRACTION

Independent, dual-review extraction and quality assessment.

DATA SYNTHESIS

The review included 64 studies comprising multivariate exposure studies (n = 47), cluster analyses (n = 11), and qualitative studies (n = 6). A National Academy of Medicine (NAM) taxonomy was an initial "best-fit" framework for organizing the synthesis of the findings. Patient characteristics associated with being HNHC included number and severity of comorbid conditions and having chronic clinical conditions, particularly heart disease, chronic kidney disease, chronic lung disease, diabetes, cancer, and hypertension. Patients' risk for being HNHC was often amplified by behavioral health conditions and social risk factors. The reviewers revised the NAM taxonomy to create a final framework, adding chronic pain and prior patterns of high health care use as characteristics associated with an increased risk for being HNHC.

LIMITATION

Little evidence distinguished potentially preventable or modifiable health care use from overall use.

CONCLUSION

A combination of characteristics can be useful for identifying HNHC patients. Because of the complexity of their conditions and circumstances, improving their quality of care will likely also require an individualized assessment of care needs and availability of support services.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality. (PROSPERO: CRD42020161179).