Publications

Background

Primary care models that offer comprehensive, accessible care to all patients may provide insufficient resources to meet the needs of patients with complex conditions who have the greatest risk for hospitalization.

Objective

To assess whether augmenting usual primary care with team-based intensive management lowers utilization and costs for high-risk patients.

Design

Randomized quality improvement trial. (ClinicalTrials.gov: NCT03100526).

Setting

5 U.S. Department of Veterans Affairs (VA) medical centers.

Patients

Primary care patients at high risk for hospitalization who had a recent acute care episode.

Intervention

Locally tailored intensive management programs providing care coordination, goals assessment, health coaching, medication reconciliation, and home visits through an interdisciplinary team, including a physician or nurse practitioner, a nurse, and psychosocial experts.

Measurements

Utilization and costs (including intensive management program expenses) 12 months before and after randomization.

Results

2210 patients were randomly assigned, 1105 to intensive management and 1105 to usual care. Patients had a mean age of 63 years and an average of 7 chronic conditions; 90% were men. Of the patients assigned to intensive management, 487 (44%) received intensive outpatient care (that is, ≥3 encounters in person or by telephone) and 204 (18%) received limited intervention. From the pre- to postrandomization periods, mean inpatient costs decreased more for the intensive management than the usual care group (-$2164 [95% CI, -$7916 to $3587]). Outpatient costs increased more for the intensive management than the usual care group ($2636 [CI, $524 to $4748]), driven by greater use of primary care, home care, telephone care, and telehealth. Mean total costs were similar in the 2 groups before and after randomization.

Limitations

Sites took up to several months to contact eligible patients, limiting the time between treatment and outcome assessment. Only VA costs were assessed.

Conclusion

High-risk patients with access to an intensive management program received more outpatient care with no increase in total costs.

Primary Funding Source

Veterans Health Administration Primary Care Services.

OBJECTIVES

To examine high-cost patients in VA and factors associated with persistence in high costs over time.

DATA SOURCES

Secondary data for FY2008-2012.

DATA EXTRACTION

We obtained VA and Medicare utilization and cost records for VA enrollees and drew a 20 percent random sample (N = 1,028,568).

STUDY DESIGN

We identified high-cost patients, defined as those in the top 10 percent of combined VA and Medicare costs, and determined the number of years they remained high cost over 4 years. We compared sociodemographics, clinical characteristics, and baseline utilization by number of high-cost years and conducted a discrete time survival analysis to predict high-cost persistence.

PRINCIPAL FINDINGS

Among 105,703 patients with the highest 10 percent of costs at baseline, 68 percent did not remain high cost in subsequent years, 32 percent had high costs after 1 year, and 7 percent had high costs in all four follow-up years. Mortality, which was 47 percent by end of follow-up, largely explained low persistence. The largest percentage of patients who persisted as high cost until end of follow-up was for spinal cord injury (16 percent).

CONCLUSION

Most high-cost patients did not remain high cost in subsequent years, which poses challenges to providers and payers to manage utilization of these patients.