Andrew Strohman January 17, 2020
The most politically prevalent challenge in the
U.S. health care system is the cost of care, and both left and right seem to
agree that managed care is a potential solution. By coordinating care among
providers, managed care systems can ensure patients receive high-quality care
at a lower cost. Some observational studies indicate coordinating care does
indeed increase quality, but the recent results from a more rigorous study,
published in the New England Journal of Medicine, appear to throw
cold water on the supposed efficacy of managed care programs.
The study examined the impact of “hotspotting,”
a strategy developed by the Camden Coalition that mirrors managed care programs
in certain ways. Hotspotting identifies “superutilizers”—those with exceedingly
high use of health care services—and connects them with an intensive,
face-to-face care approach that provides the medical care, government
benefits, and community services needed both to improve immediate health and to
reduce future utilization of health care services. In an effort to investigate
the capacity of hotspotting to improve quality of care among these
superutilizers, Amy Finkelstein from the Massachusetts Institute of
Technology and her colleagues conducted a randomized control trial to compare
health outcomes, as measured by 180-day readmission rates.
In theory, this approach to care seems
worthwhile—and it follows the overall concept of managed care. Rather than
allowing patients to repeat their vicious cycles of readmission for complex and
chronic diseases, it swiftly identifies and enrolls them into programs that
provide more comprehensive care services both inside and outside the health
care system, not only minimizing their returns but promoting self-sufficiency
to maintain their daily health.
But hotspotting doesn’t seem to work. After
separating a control group (who received the current standard of care) from the
intervention group and looking at differences in 180-day readmission rates,
there was no significant difference. In an op-ed, Finkelstein
notes regression to
the mean as one likely reason for the negative result.
This study implicates broader health care
systems and policies. Accountable Care Organizations (ACOs) and Managed
Care Organizations (MCOs), forms of managed care programs within Medicare and
Medicaid, respectively, aim to increase quality and reduce costs for the
government using a similar system to hotspotting. Should we scrap these
managed care systems because of this study?
No, but if anything this study should
encourage policymakers and researchers to look at results beyond the hospital.
Research indicates that the health care delivered within a hospital system
accounts for, at most, 10 to 20 percent
of mortality (more recent evidence places it at the low end of this range).
Factors at the level of the individual and immediate community—such as health
behaviors, genetics, socioeconomic status, and environmental
circumstances—collectively have a far greater impact. Based on this
evidence, changes to care within a hospital system will
certainly help, but the impact is constrained by the proportion of hospital
care’s contribution to health outcomes.
The results of this study focus on metrics
within the hospital system, constricting the measure of success to an area with
diminishing returns as more resources are allocated to it. Fortunately,
however, ACOs and MCOs coordinate care and connect patients with resources both
within and outside the hospital. The study has other limits, too. Using
readmission rates as the metric of success ignores other impacts of managed
care, such as potentially reducing the cost for that round of care. And the
sample came only from Camden, NJ, potentially limiting the generalizability of
the study.
Nevertheless, the results of this study call for
a much closer look at the efficacy of such approaches to improve patient costs
and outcomes. Hospital care is a large driver of health care costs, but if
we want to improve outcomes while lowering costs, any effective policy will
have to look beyond the walls of hospital systems.
https://www.americanactionforum.org/weekly-checkup/the-limits-of-managed-care-hotspotting/#ixzz6BfqjZbyR
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