Intensive care management of a complex Medicaid population: a randomized evaluation.

OBJECTIVES: Care management programs are employed by providers and payers to support high-risk patients and affect cost and utilization, with varied implementation. This study sought to evaluate the impact of an intensive care management program on utilization and cost among those with highest cost (top 5%) and highest utilization in a Medicaid accountable care organization (ACO) population. STUDY DESIGN: Randomized controlled quality improvement trial of intensive care management, provided by a nonprofit care management vendor, for Medicaid ACO patients at 2 academic centers. METHODS: Patients were identified using claims, chart review, and primary care validation, then randomly assigned 2:1 to intervention and control groups. Among 131 patients included in intent-to-treat analysis, 87 and 44 were randomly assigned to the intervention and control groups, respectively. Patients in the intervention group were eligible to receive intensive care management in the community/home setting and, in some cases, home-based primary care. Patients in the control group received standard of care, including practice-based care management. Prespecified primary outcome measures included total medical expense (TME), emergency department (ED) visits, and inpatient utilization. RESULTS: Relative to controls, patients randomly assigned to receive intensive care management had a $1933 smaller increase per member per month in TME (P = .04) and directionally consistent but nonsignificant reductions in ED visits (17% fewer; P = .40) and inpatient admissions (34% fewer; P = .29) in the 12 months post randomization compared with the 12 months prerandomization. CONCLUSIONS: Our study results support that targeted, intensive care management can favorably affect TME in a health system-based high-cost, high-risk Medicaid population. Further research is needed to evaluate the impact on additional clinical outcomes.

A population management system for improving colorectal cancer screening in a primary care setting.

RATIONALE: Provision of colorectal cancer (CRC) screening in primary care is suboptimal; failure to observe screening guidelines poses unnecessary risks to patients and doctors. AIMS AND OBJECTIVES: Implement a population management system for CRC screening; evaluate impact on compliance with evidence-based guidelines. DESIGN: A quasi-experimental, prospective quality improvement study design using pre-post-analyses with concurrent controls. SETTING: Six suites within an academic primary care practice. PARTICIPANTS: 5320 adults eligible for CRC screening treated by 70 doctors. INTERVENTION: In three intervention suites, doctors reviewed real-time rosters of patients due for CRC screening and chose practice delegate outreach or default reminder letter. Delegates tracked overdue patients, made outreach calls, facilitated test ordering, obtained records and documented patient deferral, exclusion or decline. In three control suites, doctors followed usual preventive care practices. MAIN OUTCOME MEASURES: CRC screening compliance (including documented decline, deferral or exclusion) and CRC screening completion rates over 5 months. RESULTS: At baseline, there was no significant difference in CRC screening compliance (I: 80.4% and C: 79.6%, P = 0.439) and CRC screening completion rates (I: 78.3% and C: 77.3%, P = 0.398) between intervention and control groups. Post-intervention, compliance rates (I: 88.1% and C: 80.5%, P < 0.01) and completion rates (I: 81.0% and C: 78.1%, P < 0.05) were significantly higher in the intervention group. CONCLUSIONS: A population management system using closed-loop communication may improve CRC screening compliance and completion rates within academic primary care practices. Team-based care using well-designed IT systems can enable sharing of patient care responsibilities and improve patient outcomes.