by Farhad
Modarai, Brian W.
Powers, Sandeep
Palakodeti, Vivek
Garg and Sachin
H. Jain February 27, 2020
For roughly two decades, health care organizations have
been aggressively experimenting with programs to improve care for high-need,
high-cost patients. Most of those efforts focused on care models for
chronically ill and frail elders, but organizations are now increasingly
developing programs to better serve Medicaid beneficiaries with complex health
and social needs. Although select programs appear to be effective, a recent
high-profile evaluation of one of them — the
Camden Coalition of Healthcare Providers — has raised concerns over the
utility of care models for medically and socially complex patients.
Such skepticism is premature. In an article in the new issue of the American
Journal of Managed Care, we published encouraging results from a
complex-care-management program serving high-need, high-cost Medicaid patients
in Memphis, Tennessee. The program, built on top of an existing integrated–care model, lowered total spending by keeping
patients out of the hospital. We believe our experience with this program
offers important lessons for others seeking to design and implement their own
complex-care-management programs.
CareMore Health — a physician-led
integrated-care-delivery system that’s part of Anthem Inc. — began
providing comprehensive care services to Medicaid beneficiaries in Memphis in
2015. An early analysis of our patient population revealed that spending was
remarkably concentrated: The costliest 5% of patients incurred roughly 70% of
all spending. Most had multiple chronic medical conditions, often with
co-occurring behavioral health disorders. Many also had significant social
needs, ranging from housing instability to food insecurity. As part of an integrated-care-delivery strategy, CareMore
developed a program aimed at providing high-touch, comprehensive care for these
complex patients.
In designing the program, we drew on our experiences
caring for Medicaid patients and from existing programs that targeted medically
and socially complex patients. We augmented our primary care physician-led medical home model with
a full-time community health worker and greater support from social workers.
Patients who enrolled in the program underwent a comprehensive,
multi-disciplinary assessment of their medical and social needs, the results of
which were used to create a tailored care plan.
Patients in the program received frequent, structured follow-ups.
The community health worker contacted patients weekly (via the phone or in
person) to check in, evaluate progress, and address barriers to their adherence
to the care plan (e.g., transportation or health literacy). The community
health worker, social worker, and primary care physician reviewed the care plan
weekly, re-prioritizing tasks and assigning new responsibilities. Patients
returned to CareMore care centers monthly for in-person visits with the entire
team. Additional follow-ups were customized. The community health worker
accompanied some patients to specialist visits and social service appointments.
The social worker provided counseling for behavioral health needs, helped
navigate social services, and arranged for necessary referrals and medical
equipment. The primary care physician saw patients in the office to address
gaps in care and stabilize chronic conditions.
Results and impact. To disentangle the effect of the program from unrelated
changes in utilization (including regression to the mean), we evaluated its
impact through a randomized controlled trial. We found that the program led to
a $7,732 (or 37%) reduction in total medical spending per patient per year.
This was driven primarily by decreases in hospital utilization: Patients were
less likely to be admitted to the hospital (50% decrease), and when they were
admitted, their hospital stays were shorter (62% decrease). We also saw a small
decline in specialist visits, possibly due to more active management of chronic
illnesses by the primary care physician. Patients were highly satisfied with
the program: Its net promoter score (measured three months after enrollment in
the program) was 100 out of 100.
Here are lessons for others.
Precise patient targeting can improve effectiveness and
efficiency. We used predictive models, claims
data, clinical criteria, and clinician judgment to identify the patients most
likely to benefit most from complex-care management, rather than focusing only
on patients who incurred high costs in the prior year. Incorporating clinician
judgment allowed us to harness the intuition and wisdom of care team
members — and we found that patients referred to the program based on
clinician judgment were more likely to engage with the program and experienced
greater reductions in spending and hospital utilization.
Programs with an integrated model for addressing medical
and social risk may be most effective. We
augmented our existing integrated-care model with increased staffing,
resources, and protocols to identify and manage social risk. Close integration
between the community health worker and primary care physician was necessary to
rapidly address the social drivers of poor health outcomes
and unnecessary hospitalizations. For example, after one of our community
health workers discovered that a patient was no longer able to afford his
insulin, she immediately alerted his primary care physician, who prescribed a
more affordable regimen within an hour.
Focus only on the most relevant drivers of poor
outcomes. Our planning process began by identifying
the unique drivers of poor outcomes for each individual patient. Specific
attention was paid to the drivers that mattered most to patients and those that
could be addressed over the following weeks to months. For patients with
multiple social risks (e.g., housing instability, poverty, loneliness, food
insecurity), this exercise helped clarify where to direct early attention and
resources, allowing for rapid stabilization in many of the most complex cases.
Partner with community-based organizations and
social-safety-net institutions such as food banks and housing authorities. Blind referrals and attempts to coordinate services
in real time are often bureaucratic and cumbersome, resulting in long wait
times for patients who need quick attention. Building trusting, longitudinal
relationships with organizations in the Memphis area was critical for our
patients. For example, we discovered that one patient in our program was
frequently utilizing the emergency department due to a lack of safety and
support in his group home. Drawing on connections we had built with group homes
in the community, we were able to help the patient rapidly transfer to a more
supportive home, bypassing traditional administrative hurdles and wait times.
What’s next for the field?
Our results and those of other successful models suggest that carefully
designed and targeted programs can improve care and reduce spending for
high-need, high-cost Medicaid patients. What’s needed now is a better
understanding of which program elements work best for specific patient groups
and what it takes to rapidly scale successful interventions. Important work in
this area is already underway at places like the University of Pennsylvania. At CareMore, we
are standardizing workflows, implementing our model across new markets, and
closely measuring its impact.
The United States needs a broader commitment to improving
the health and social services provided to complex Medicaid patients. If ever
there was a population that demands our persistence, ingenuity, and commitment
to finding delivery models that work, it’s the highest-need patients in
communities like Memphis.
The authors would like to acknowledge the contributions
of Manisha Sharma, Caroline Hagan, Paula Ma, Brisa Samudio, Yolanda Sutton, and
Nupur Mehta.
Farhad Modarai, DO, is
an associate regional medical officer in North Carolina at CareMore Health, a
division of Anthem, Inc. He is also consulting associate faculty at Duke
University’s Department of Family Medicine and Community Health.
Brian W. Powers, MD, is
a physician and researcher at Brigham and Women’s Hospital and director of
population health strategy and analytics at CareMore Health, a division of
Anthem, Inc.
Sandeep Palakodeti, MD,
is a regional medical officer at CareMore Health, a division of Anthem, Inc. He
previously was a senior associate consultant at the Mayo Clinic, where he
practiced as an academic hospitalist, and was cofounder and chief medical
officer of Sherbit.io, an AI-based health analytics company acquired by
Medopad.
Vivek Garg, MD, is chief
medical officer at CareMore Health, a division of Anthem, Inc. He previously
was director of medical operations at Oscar Health, clinical assistant
professor at Weill Cornell Medicine, and medical director at One Medical Group.
Sachin H. Jain, MD, is
president and CEO of CareMore and Aspire Health, the care delivery
divisions of Anthem, Inc. He is also a consulting professor of medicine at the
Stanford University School of Medicine. Follow him on Twitter at @sacjai.
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