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

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. Randomized controlled quality improvement trial of intensive care management, provided by a nonprofit care management vendor, for Medicaid ACO patients at 2 academic centers. 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. 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. 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.