Tailoring Complex-Care Management, Coordination, and Integration for High-Need, High-Cost Patients: A Vital Direction for Health and Health Care

Blumenthal, David; Anderson, Gerard F.; Burke, Sheila; Fulmer, Terry; Jha, Ashish K.; Long, Peter

doi:10.31478/201609q

Cited by 22 publications

(30 citation statements)

References 19 publications

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“…Although these programs were created using clinically informed designations of HNHC, evidence suggests that the absence of system‐level efficacy in reducing utilization and costs for these programs is partly related to a lack of empirical classification of HNHC cohorts. In fact, many researchers have acknowledged the need to identify subgroups that go beyond individual medical diagnoses within the HNHC population if health systems are to adopt interventions targeted to the specific needs for each subgroup with improved accuracy …”

Section: Discussionmentioning

confidence: 99%

“…This heterogeneity can complicate attempts to intervene in this population because a one‐size‐fits‐all approach may not work for all HN patients. Improved understanding of the different subgroups that exist within the HN population can be used to explore variation in utilization patterns among the subgroups, some of which may be modifiable . Identification of HN subgroups with modifiable utilization patterns represents a powerful tool for health systems, allowing them to better classify and manage complex patients at risk of poor outcomes and to develop targeted intervention programs for the HN population.…”

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confidence: 99%

“…Identification of HN subgroups with modifiable utilization patterns represents a powerful tool for health systems, allowing them to better classify and manage complex patients at risk of poor outcomes and to develop targeted intervention programs for the HN population. As a result, improved understanding of the subpopulations present within the HN population was declared a research priority …”

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confidence: 99%

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High‐Need Phenotypes in Medicare Beneficiaries: Drivers of Variation in Utilization and Outcomes

Keeney

Bélanger

Jones

et al. 2019

J American Geriatrics Society

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OBJECTIVES High‐need (HN) Medicare beneficiaries heavily use healthcare services at a high cost. This population is heterogeneous, composed of individuals with varying degrees of medical complexity and healthcare needs. To improve healthcare delivery and decrease costs, it is critical to identify the subpopulations present within this population. We aimed to (1) identify distinct clinical phenotypes present within HN Medicare beneficiaries, and (2) examine differences in outcomes between phenotypes. DESIGN Latent class analysis was used to identify phenotypes within a sample of HN fee‐for‐service (FFS) Medicare beneficiaries aged 65 years and older using Medicare claims and post‐acute assessment data. SETTING Not applicable. PARTICIPANTS Two cross‐sectional cohorts were used to identify phenotypes. Cohorts included FFS Medicare beneficiaries aged 65 and older who survived through 2014 (n = 415 659) and 2015 (n = 416 643). MEASUREMENTS The following variables were used to identify phenotypes: acute and post‐acute care use, functional dependency in one or more activities of daily living, presence of six or more chronic conditions, and complex chronic conditions. Mortality, hospitalizations, healthcare expenditures, and days in the community were compared between phenotypes. RESULTS Five phenotypes were identified: (1) comorbid ischemic heart disease with hospitalization and skilled nursing facility use (22% of the HN sample), (2) comorbid ischemic heart disease with home care use (23%), (3) home care use (12%), (4) high comorbidity with hospitalization (32%), and (5) Alzheimer's disease/related dementias with functional dependency and nursing home use (11%). Mortality was highest in phenotypes 1 and 2; hospitalizations and expenditures were highest in phenotypes 1, 3, and 4. CONCLUSIONS Our findings represent a first step toward classifying the heterogeneity among HN Medicare beneficiaries. Further work is needed to identify modifiable utilization patterns between phenotypes to improve the value of healthcare provided to these subpopulations. J Am Geriatr Soc 68:70–77, 2019

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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High‐Need Phenotypes in Medicare Beneficiaries: Drivers of Variation in Utilization and Outcomes

Keeney

Bélanger

Jones

et al. 2019

J American Geriatrics Society

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“…Care coordination can be an important strategy to address their complexities 5–7 ; however, limited mechanisms are available to provide greater coordination in traditional Medicare (TM). Medicare Advantage (MA) was designed to fill that gap.…”

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confidence: 99%

Analysis of Drivers of Disenrollment and Plan Switching Among Medicare Advantage Beneficiaries

et al. 2019

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IMPORTANCE How often enrollees with complex care needs leave the Medicare Advantage (MA) program and what might drive their decisions remain unknown. OBJECTIVE To characterize trends in switching to and from MA among high-need beneficiaries and to evaluate the drivers of disenrollment decisions. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of MA and traditional Medicare (TM) enrollees from January 1, 2014, through December 31, 2015, used a multinomial logit regression stratified by Medicare-Medicaid eligibility status. All 14 589 645 non-high-need MA enrollees and 1302 470 high-need enrollees in the United States who survived until the end of 2014 were eligible for the analysis. Data were analyzed from November 1, 2017, through August 1, 2018. EXPOSURES Enrollee dual eligibility and high-need status (based on complex chronic conditions, multiple morbidities, use of health care services, functional impairment, and frailty indicators), MA plan star rating, and cost sharing. MAIN OUTCOMES AND MEASURES The proportion of enrollees who disenrolled into TM, remained in the same MA plan, or who switched plans within the MA program. RESULTS A total of 13 901 816 enrollees were included in the analysis (56.2% women; mean [SD] age, 70.9 [9.9] years). Among the 1302 470 high-need enrollees, an adjusted 4.6% (95% CI, 4.5%-4.6%) of Medicare-only and 14.8% (95% CI, 14.5%-15.0%) of Medicare-Medicaid members switched from MA to TM compared with 3.3% (95% CI, 3.3%-3.3%) and 4.6% (95% CI, 4.5%-4.7%), respectively, among non-high-need enrollees. Among enrollees in low-quality plans, 23.0% (95% CI, 22.3%-23.9%) of Medicare and 42.8% (95% CI, 40.5%-45.1%) of dual-eligible high-need enrollees left MA. Even in high-quality plans, high-need members disenrolled at higher rates than non-high-need members (4.9% [95% CI, 4.6%-5.2%] vs 1.8% [95% CI, 1.8%-1.9%] for Medicare-only enrollees and 11.3% vs 2.4% dual eligible enrollees). Enrollment in a 5.0-star rated plan was associated with a 30.1-percentage point reduction (95% CI, −31.7 to −28.4 percentage points) in the probability of disenrollment among high-need individuals. A $100 increase in monthly premiums was associated with a 33.9–percentage point increase (95% CI, −34.9 to −33.0 percentage points) in the likelihood of switching plans, and a small reduction in the likelihood of disenrolling (−2.7 percentage points; 95% CI, −3.2 to −2.2 percentage points). Among Medicare-Medicaid eligible participants, 14.1% (95% CI, 14.0%-14.2%) of high-need and 16.7% (95% CI, 16.6%-16.7%) of non-high-need enrollees switched from TM to MA. CONCLUSIONS AND RELEVANCE Results of this study suggest that substantially higher disenrollment from MA plans occurs among high-need and Medicare-Medicaid eligible enrollees. This study’s findings suggest that star ratings have the strongest association with disenrollment trends, whereas increases in monthly premiums are associated with greater likelihood of switching plans.

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“…Increasingly, ACOs are integrating high‐risk populations who have a higher than average probability of health care utilization or cost . High‐risk populations often have complex medical needs requiring care and service from multiple providers and therefore have the potential to benefit substantially from coordinated care provided by the ACO model . In contrast, traditional fee‐for‐service (FFS) arrangements lack financial incentives for providers to coordinate care.…”

Section: Introductionmentioning

confidence: 99%

How does being part of a pediatric accountable care organization impact health service use for children with disabilities?

Song

Chisolm

et al. 2019

Health Services Research

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Objective To examine the impact of a Medicaid‐serving pediatric accountable care organization (ACO) on health service use by children who qualify for Medicaid by virtue of a disability under the “aged, blind, and disabled” (ABD) eligibility criteria. Data Sources/Study Setting We evaluated a 2013 Ohio policy change that effectively moved ABD Medicaid children into an ACO model of care using Ohio Medicaid administrative claims data for years 2011‐2016. Study Design We used a difference‐in‐difference design to examine changes in patterns of health care service use by ABD‐enrolled children before and after enrolling in an ACO compared with ABD‐enrolled children enrolled in non‐ACO managed care plans. Data Collection/Extraction Methods We identified 17 356 children who resided in 34 of 88 counties as the ACO “intervention” group and 47 026 ABD‐enrolled children who resided outside of the ACO region as non‐ACO controls. Principal Findings Being part of the ACO increased adolescent preventative service and decreased use of ADHD medications as compared to similar children in non‐ACO capitated managed care plans. Relative home health service use decreased for children in the ACO. Conclusions Our overall results indicate that being part of an ACO may improve quality in certain areas, such as adolescent well‐child visits, though there may be room for improvement in other areas considered important by patients and their families such as home health service.

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Tailoring Complex-Care Management, Coordination, and Integration for High-Need, High-Cost Patients: A Vital Direction for Health and Health Care

Cited by 22 publications

References 19 publications

High‐Need Phenotypes in Medicare Beneficiaries: Drivers of Variation in Utilization and Outcomes

High‐Need Phenotypes in Medicare Beneficiaries: Drivers of Variation in Utilization and Outcomes

Analysis of Drivers of Disenrollment and Plan Switching Among Medicare Advantage Beneficiaries

How does being part of a pediatric accountable care organization impact health service use for children with disabilities?

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