In the drive to reduce costs, some health systems have been testing intensive management models to augment primary care for high-risk, “sickest-of-the-sick” patients who might otherwise require expensive inpatient care. Now a new study suggests that any hoped-for savings may actually be elusive, although it could point to more effective ways in which resources might be directed.
The analysis included more than 2000 patients at five sites managed by the US Department of Veterans Affairs (VA) and showed that individuals who received care from an intensive management team working in conjunction with their usual primary care clinicians incurred no net changes in costs, but made greater use of outpatient services such as health coaching, home visits, and medication reconciliation than patients assigned to usual care, Jean Yoon, PhD, MHS, and coauthors write.
This shifting of costs from inpatient to outpatient care and the overall cost “neutrality” of the added intensive services suggest “that a potential exists to change how care is delivered,” they explain. “Primary care practices may consider implementing intensive management programs with these findings in mind.”
However, to realize their full potential, those intensive programs must be redesigned to maximize patient participation, the authors add. They
publishedtheir findings online June 4 in the
Annals of Internal Medicine.
Yoon, from the VA Health Economics Resource Center and Center for Innovation to Implementation, Menlo Park, California, and the University of California, San Francisco, School of Medicine, and coauthors conducted a randomized controlled, quality improvement trial at five VA sites in geographically diverse areas across the United States. The study included patients with a recent history of a visit to a hospital or emergency department, and a score in the 90th percentile for 90-day hospitalization on a validated risk-predicting algorithm.
The study recruited participants from July 21, 2014, to August 28, 2015, and randomly assigned them by site and sex to the intensive management team or to usual care. The intensive management team conducted patient evaluations, made care recommendations on the basis of those evaluations, and actively followed patients who accepted the intensive services in addition to their usual primary care. The authors compared resource utilization and costs for each patient during the 12 months before and the 12 months after their assignment.
The groups each consisted of 1105 patients. Men made up approximately 90% of each cohort, with a mean age of 63.3 years (standard deviation, 12.4) in the intensive-management group and 62.3 years (standard deviation, 12.7) in the usual-care group (P = .08). There were no significant differences in other baseline characteristics between the two groups.
In general, patients in the intensive management group were older, less likely to be never married, had higher rates of chronic illnesses such as diabetes and depression, had used more primary care services at baseline, and had lower rates of schizophrenia and drug or alcohol dependence compared with patients in the usual care group (all standardized mean differences, >0.01).
Only 487 (44%) of the patients in the intensive management group received the full intervention, which the authors defined as “three or more encounters in person or by telephone from the intensive management team.” These patients had a mean of 14.0 encounters (range, 3 – 116) compared with 0.4 (range, 0 – 2) experienced by the other individuals in that group. Most of the intensive interventions were for home care, social work services, and mental health or substance use disorder care.
Of the patients in the intensive management group, 204 (18%) did not fully participate or were offered only limited services, and the team determined that 414 (37%) would not benefit from those services or could not be contacted.
Few Differences Between Groups
On unadjusted analysis, patients in the intensive management group incurred a mean of $31,956 (95% confidence interval [CI], $29,480 – $34,433) in total healthcare costs in the 12 months before the study, and a mean of $31,878 (95% CI, $28,848 – $34,909) in the 12 months afterward. For patients in the usual care group, unadjusted mean costs were $32,536 (95% CI, $29,851 – $35,222) and $31,904 (95% CI, $28,528 – $35,280), respectively.
After adjustment for patient demographic factors and health conditions diagnosed during the year before randomization, total healthcare costs for patients in the intervention group were $471 (95% CI, −$6347 to $7290) higher than in the control group. Patients in the intervention group had higher mean adjusted costs for primary care, including home-based primary care, but lower costs for mental health intensive case management. There were no other significant cost differences between the groups.
The authors also found no significant differences between the groups in rates of hospitalization “with regard to mean number of inpatient stays, inpatient days, or emergency department visits in the postintervention period,” they write. Patients in the intensive management group did have significantly fewer nursing home days than the usual care group (incidence rate ratio, 0.35; 95% CI, 0.13 – 0.95). The intensive management group also made greater use of outpatient services such as primary care, care management, mental health and substance use disorder care, and home, geriatrics, and palliative or hospice care.
Mortality during the 12-month follow-up period in the intensive management and usual care groups was 5.9% vs 5.5%, respectively (P = .93).
“[O]verall, the intensive management programs seem to have been associated with cost shifting from inpatient to outpatient care,” the authors write. Thanks to the comprehensive assessments performed by the intensive management teams, the findings suggest that these programs “could identify unmet needs and connect patients to important resources.”
However, the authors add that patients with substance use disorders or more serious mental illnesses may find it harder to engage with the management team and may require different models of care.
Study limitations include inability to generalize from these five VA sites to the rest of the country, the possibility that a 12-month follow-up may have been insufficient for detecting significant changes in use of care, no information on prescription drug use or visits to non-VA sites, and lack of access to Medicare data.
Although the intensive management teams were able to help complex patients find outpatient services that met their needs, the fact that only 62% participated “suggests that better methods are needed to efficiently target the high-risk patients most likely to benefit from outpatient care,” the authors conclude. “Overall, our findings and those of other studies suggest that improvements in the design of intensive management programs are not only possible but necessary for this approach to achieve its full desired benefits.”
The authors have disclosed no relevant financial relationships.
Ann Intern Med. Published online June 4, 2018.
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