In the end, the program succeeded in signing up more than half the target group, and effectively engaged 45 percent of the total targeted group in active self-management.

Assigned care managers would accompany patients on clinic visits to their primary care physicians and encourage the patients to collaborate with the doctors on self-management plans. The care managers also tried to keep providers informed about
what was going on with their patients. They would convene regular meetings with providers to discuss patient status and solve problems in the program’s operations, including electronic hurdles in sharing patient data.

The typical KCCP client had a primary care physician, one or more physician specialists, a mental health provider, entitlement program caseworkers, and perhaps a nutritionist, a diabetic educator and a social worker. That complexity can be very confusing,
especially for patients with limited education, cognitive or psychosocial impairments and language barriers.

“There are a lot of cooks in the kitchen and it’s challenging for one person, such as the primary care physician, to see the
big picture,” says Debra Morrison, behavioral health program manager at Neighborcare Health. “It’s invaluable to have someone pulling together the pieces, facilitating communication. I think a lot of the patients who participated gained a lot. They felt cared for, made progress on their goals, and learned to utilize health care service more effectively.”

Still, the overall results of the demonstration were mixed. A University of Washington evaluation report earlier this year did not find evidence of significant savings in overall Medicaid costs for patients offered KCCP services, possibly because only 45 percent actively engaged in the services and the average follow-up was only one year.

Lessler argues, though, that achieving 45 percent engagement – meaning completion of a patient assessment and development of patient health goals – was a relative success given the experience of other programs around the country.

Similarly, the evaluation of the pilot found there were no significant net Medicaid savings for patients who actually participated in KCCP. But this group showed significant increases in desirable utilization of services – including outpatient visits, prescription drugs, home care and support, mental health and chemical dependency treatment – along with decreased homelessness.

In addition, unplanned hospital admissions increased at a slower rate for active KCCP patients than for the control group, and also resulted in a two percent decrease in monthly per beneficiary costs compared with a 49 percent increase in the control group.
The program seemed particularly effective for participating beneficiaries with alcohol or drug problems.

For patients in this group, total Medicaid costs dropped, possibly because they were more likely to receive alcohol- or chemical dependency treatment. “What you see overall is KCCP clients received more access to needed services, a reduction in hospital admissions preceded by an emergency room visit and decreases in homelessness,” said Toni Krupski, a research associate
professor at University of Washington. “But the impact is not enough at this time to offset the actual cost of the intervention. The intervention may hold down medical costs primarily for those with alcohol and drug treatment needs.”

She noted, however, that high-cost Medicaid patients with serious chronic problems may need to be followed for two to four years to see the full impact of KCCP’s efforts. 

In July, Washington began moving all Medicaid-only, SSI-eligible, disabled beneficiaries into five private managed care plans under its new Healthy Options program. Based on findings from KCCP as well as other chronic care management programs in the state, Washington is requiring the plans to provide community-based care management services to the estimated 48,000 Medicaid-only high-risk beneficiaries statewide, and it is negotiating with the plans on how to do this, says Bea Rector, project director for the state Aging and Disability Services Administration. All plans will have to offer a state-certified care management network.

KCCP’s Lessler expresses hope that his and his colleagues’ work in organizing a community-wide care management system, which was beginning to have a significant impact, will provide a framework for care management in the state. “The ability of managed care
organizations to break even or make a profit will depend on how well they manage these very sick people,” he says.

Similarly, the state acknowledges the KCCP pilot as a valuable investment, having cultivated a seasoned team of experts on complex Medicaid populations headed by Dr. Lessler — a particularly important resource as the state looks toward health homes and the
Medicaid expansion.

This article was originally published by the Center for Health Care Strategies.