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Texas A&M researcher finds that a targeted care management initiative improves health outcomes and lowers costs
A new study by Benjamin Ukert, PhD, of the Texas A&M University School of Public Health found that targeted outreach efforts may improve care for patients with chronic heart failure while also lowering health care costs.
Published in the December 2022 edition of the American Journal of Managed Care, the study evaluated care management outreach initiatives that encourage and support patients’ disease management. These initiatives are designed to identify and close care gaps between physician visits—such as when patients do not follow a prescribed medication treatment plan or do not schedule regular follow-up appointments or tests.
These initiatives traditionally have used a nurse line in which nurses were assigned a list of patients to call. “The nurse line would help manage patient care, whether through organizing transportation for the patient, scheduling doctor’s appointments, or handling other tasks,” Ukert said.
However, not all patients benefit equally from care management programs. Some individuals are well equipped to manage their disease, while others require substantial help. To mitigate this issue, an insurance company developed an algorithm that calculated a risk score of the potential for hospitalization for each patient with chronic heart failure. The risk score enabled the insurer to create a prioritized list of contacts to guide nurses in whom to contact first.
In this study, the researchers compared the traditional nurse line and the targeted outreach efforts that used the algorithm using insurance data from Medicare Advantage patients who had chronic heart failure during 2013–2018. “We really tried to evaluate whether this algorithm that the insurer ran has a benefit and ask whether it benefits individuals who are at-risk of a potential hospitalization and health care encounter that they may not want,” Ukert said.
Their analysis found the targeted care coordination approach supported the patient’s quality of health more than a general care coordination program.
“The algorithm and the subsequent outreach led to lower hospitalizations for those people who received the call because of the algorithm, as compared to those untargeted patients who received a call,” Ukert said, adding that this finding may support the use of the targeted approach with patients with some health conditions. “How to define who would benefit the most is not easy—it depends on diagnosis and disease group. In this case, the targeted outreach for congestive heart failure seemed to work with a targeted approach.”
The study also found that the care coordination approach that utilized the algorithm saved $1,500 in total cost per patient annually. These savings were associated with fewer emergency department visits; hospitalization cost reductions were not calculated as part of this study.
“Saving money for high-risk groups is really hard because they have so many medical needs. There are potentials to improve care, but they seem to be happening on the outpatient side, instead of being related to hospitalization,” Ukert said. “Once somebody has to have a hospitalization, there seems to be little that can be done to minimize costs. The holy grail is to try to do as much as you can on the outpatient side, rather than escalate and wait until the last second to intervene.”
Co-authors were Guy David, PhD, of the University of Pennsylvania and Aaron Smith-McLallen, PhD, of Independence Blue Cross.
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