Academic journal article
By Weir, Sharada; Aweh, Gideon; Clark, Robin E.
Health Care Financing Review , Vol. 30, No. 1
As health care costs rise for all payers, Medicaid programs are faced with the dual challenges of providing appropriate health care for some of society's most vulnerable members and containing costs. Direct controls, such as limiting eligibility for programs or access to needed services, are unlikely to produce net budgetary relief, since public funds ultimately may be tapped for costly urgent care for those who cannot get treatment by other means. Targeting high-cost patients for enhanced care management is another approach to defending limited funds against increasing health care costs. The care management approach seeks to engage consumers in self-management of chronic conditions, while supporting physician adherence to evidence-based care guidelines in an effort to reduce the demand for future high cost, preventable utilization. Cost savings are not guaranteed, but the potential to simultaneously reduce costs and improve health outcomes is appealing.
As part of Act 191, Vermont's health care reform legislation, OVHA, which manages their publicly-funded health insurance programs, established a pair of integrated programs to offer care management services to all chronically ill members in the State who meet qualifying criteria (Maxwell, 2007; Office of Vermont Health Access, 2007a). In general, members must have been diagnosed with one or more of 11 chronic conditions (1): (1) asthma, (2) diabetes, (3) chronic obstructive pulmonary disease, (4) low back pain, (5) congestive heart failure, (6) ischemic heart disease, (7) rheumatoid arthritis, (8) hypertension, (9) disorders of lipid metabolism, (10) depression, and (11) chronic renal failure. (2) Members with Medicare or other major third party insurance are ineligible, as are those in pharmacy-only benefit programs and programs that are paid from non-Medicaid funding sources.
The Chronic Care Management Program (CCMP) serves the majority of the State's Medicaid beneficiaries with one or more chronic conditions. Member-level interventions range from mailings of condition-specific self-management literature and telephone access to health coaches to the development of an individual care plan and face-to-face patient support, depending on the needs of the member (Office of Vermont Health Access, 2008). The Care Coordination Program (CCP) is an intensive case management program staffed by teams of nurses and social workers and funded to serve the top 5 to 10 percent of eligible members with chronic conditions.
One challenge for the CCP is predicting which members are at greatest risk for costly and preventable service utilization. In the initial phase of program development, cases were selected based on prior cost and health care utilization (i.e., emergency department and acute inpatient hospitalization). Systems were put in place to facilitate referrals from hospitals and emergency departments, and cases could also be referred from outside sources (e.g., primary care physicians) (Office of Vermont Health Access, 2007b). Adoption of these recruitment techniques was expedient, helping the program get off the ground. However, as the CCP develops and matures, considerations of efficiency and equity become increasingly important. Although prior cost and utilization can help to predict future resource use, by themselves they are somewhat crude indicators in that they do not distinguish between transitory and chronic needs. Prediction of future cost can be greatly enhanced by taking into account prior diagnoses.
Health risk predictive modeling is a methodological approach that uses clinical diagnostic information to predict future cost. While there will always be room for referral systems in a program such as the CCP, basing initial case selection on health risk predictive modeling output enables the program to efficiently evaluate all eligible members. It may help to identify at-risk patients who do not have effective physician advocates and provide timely assessment of risk before patients require emergency department or inpatient care. …