RESUMEN
OBJECTIVES: The purpose of our study was to assess the relationship between intervention dosage and hospital utilization outcomes among patients with complex health and social needs enrolled in a care management program. We highlight the importance of measuring patient engagement and intervention dosage in program evaluation. STUDY DESIGN: We performed a secondary analysis of data collected between 2014 and 2018 as part of a randomized controlled trial of the Camden Coalition's signature care management intervention. Our analytical sample consisted of 393 patients. METHODS: We calculated a time-invariant cumulative dosage rank based on the number of hours spent by care teams working with or on behalf of patients and then divided patients into low- and high-dosage groups. We applied propensity score reweighting to compare hospital utilization outcomes between patients in these 2 groups. RESULTS: Compared with patients in the low-dosage group, those in the high-dosage group had a lower readmission rate at 30 (21.6% vs 36.6%; P < .001) and 90 (41.7% vs 55.2%; P = .003) days post enrollment. The difference between the 2 groups at 180 days post enrollment was not statistically significant (57.5% vs 64.9%; P = .150). CONCLUSIONS: Our study elucidates a gap in how care management programs for patients with complex health and social needs are evaluated. Although the study shows an association between intervention dosage and care management outcomes, patients' medical complexity and social circumstances are among the factors that can attenuate the dose-response relationship over time.
RESUMEN
Accountable Care Organizations (ACOs) aim to reduce health care costs while improving patient outcomes. Camden Coalition of Healthcare Providers' (Camden Coalition) work already aligned with this aim before receiving state approval to operate a certified Medicaid ACO in New Jersey. Upon its formation, the Camden Coalition ACO partnered with UnitedHealthcare and, through state legislation, Rutgers Center for State Health Policy (CSHP) was established as its external evaluator. In evaluating the Camden Coalition ACO, Rutgers CSHP built on the Medicare Shared Savings model, but modified it based on the understanding that the Medicaid population differs from the Medicare population. Annual savings rate (ASR) was used to measure shared savings, and was calculated at the Medicaid product level and aggregated up to reflect a single ASR for the first performance year. The calculated performance yielded a range of shared savings from an ASR of 0.4% to 5.3%, depending on which dollar amount was used to create the outlier ceiling (limit at which a subset of members with expensive utilization patterns are excluded) and how the appropriate statewide trend factor (the expected percentage increase in Medicaid costs across the state) was chosen. In all scenarios, the ASR resulted in less cost savings than predicted. The unfavorable results may be caused by the fact that the evaluation was not calibrated to capture areas where Camden Coalition's ACO was likely to make its impact. Future ACO evaluations should be designed to better correlate with the patient populations and practice areas of the ACO.
