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Cutting high-risk patient costs with . . . more care?

A pilot King County program is taking aim at high-risk, high-cost medicaid patients with a simple concept: More help.

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“The nurses say it has changed their lives and the way they look at patient interaction,” says Rosemary Cunningham, KCCP’s
strategic planning manager. “It has transformed our agency at all levels.”

At its start in 2009, KCCP initially focused on about 1,500 high-risk, SSI-eligible Medicaid beneficiaries in King County with chronic illness and behavioral health needs who had received care from one of the participating clinics within the previous year. A predictive modeling tool was used to identify this initial target group of individuals with expected health care costs 50 percent higher than average.

Beneficiaries were randomly assigned either to the KCCP demonstration or to a control group whose members would receive care management services after the trial.

During the start-up and pilot phase, the state ended up paying, through KCCP, about $500 a month for each beneficiary who actively participated. This covered at least three to six months of enrollment outreach, support for care coordinators in the participating clinics, and start-up infrastructure costs such as building a data system. The state mailed multiple carefully crafted letters to the eligible
beneficiaries notifying them of the new program and its benefits.

The state gave the names of the selected beneficiaries to KCCP staff, who then tried to track down the patients by phone and enroll them. That was no easy task given that many of these people lived chaotic lives and some were homeless. The contact information was often out of date, or the person might be ineligible for Medicaid, in jail or deceased. KCCP’s Caroline Bacon said she had to
do lots of detective work, checking various data bases, contacting probation officers, or calling the person’s listed medical provider.

Some beneficiaries read the state’s introductory letter and were receptive to Bacon’s follow-up call. But others never received or opened the letter and were guarded when Bacon called. That’s where the training in motivational interviewing and respectful listening
helped. Mary Pat O’Leary, KCCP’s clinical supervisor, overheard Bacon making many of these calls.

Sometimes, O’Leary says, the person initially would say they weren’t interested. “Caroline would say, ‘Oh, it sounds like you’re already well connected with your doctor.’ Then there would be a pause. And Caroline would say, “Oh, you would like to enroll.’ ”

Bacon then would start the patient assessment and schedule a time and a place for a nurse care manager to visit the patient. While the care managers preferred to visit patients at home to assess the home environment, they deferred to patients’ frequent preference
to meet at a library, coffeehouse, the local Recovery Café, at a shelter, or at the KCCP office.

While some patients did not show up for scheduled meetings, KCCP staff enjoyed successes in persuading patients who initially turned them away at the door to open up and seek medical or detox treatment. “You have to appreciate the small wins and encourage
people on their small steps, such as losing one pound or lowering their blood sugar a little,” O’Leary says.

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.


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Comments:

Posted Fri, Nov 16, 6:35 p.m. Inappropriate

And just how effective was this study -- did anyone participating actually get on their own feet and was able to land a job and care for themselves. Why spend so much money coaxing people to go to a doctor when there are plenty of people out there that need and want a doctor and can't afford it. Help those that want help first. Bacon can continue her groundbreaking work on her own dime -- bet she has a change of heart if she didn't get paid.

Norge

Posted Fri, Nov 16, 11:35 p.m. Inappropriate

Norge, the point of this Medicaid care management/coordination program, as I thought I explained in the article, is to reduce Medicaid costs for these high-cost, high-risk beneficiaries. All around the country, in both private and public health plans, a small percentage of people account for a hugely disproportionate share of the costs. Are we going to allow this small group to continue to drive up costs for everyone, or are we going to find ways to manage and improve their care to keep their healthier and out of the hospital and emergency room -- and thus control costs for taxpayers and insurance policyholders? Employers, health insurers, state Medicaid programs, Medicare, and health care providers have decided they are going to find ways to keep that high-risk group healthier. That's what this King County program is about.

Posted Sun, Nov 18, 4:58 p.m. Inappropriate

This doesn't really reduce any costs at all, it just shifts that burden somewhere else. Too bad that somewhere else isn't on the people who are really are the cause of the problem, they will just continue to dodge taking responsibility for their actions and poor choices.

Djinn

Posted Wed, Nov 21, 10:04 a.m. Inappropriate

Listen to what Aetna's CEO said about this on NPR this morning, in the last two minutes of the interview:
http://www.npr.org/2012/11/21/165629956/fixing-health-care-waste-would-trip-deficit

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