Do payor-based outreach programs reduce medical cost and utilization?

ABSTRACT

There is growing interest in using predictive analytics to drive interventions that reduce avoidable healthcare utilization. This study evaluates the impact of such an intervention utilizing claims from 2013 to 2017 for high-risk Medicare Advantage patients with congestive heart failure. A predictive algorithm using clinical and nonclinical information produced a risk score ranking for health plan members in 10 separate waves between July 2013 and May 2015. Each wave was followed by an outreach intervention. The varying capacity for outreach across waves created a set of arbitrary intervention treatment cutoff points, separating treated and untreated members with very similar predicted risk scores. We estimate a difference-in-differences model to identify the effects of the intervention program among patients with a high score on care utilization. We find that enrollment in the intervention decreased the probability and number of hospitalizations (by 43% and 50%, respectively) and emergency room visits (10% and 14%, respectively), reduced the time until a primary care visit (8.2 days), and reduced total medical cost by $716 per month in the first 6 months following outreach.