Integrating services can help high-risk Medicaid beneficiaries

A Center for Health Care Strategies (CHCS) first-of-its-kind Medicaid demonstration project that tested integrating health services for beneficiaries with multiple chronic conditions has found that such efforts appear particularly promising in generating quality improvements and reducing hospital admissions. An evaluation of the project also found that Medicaid purchasers, plans, and providers are willing and able to test groundbreaking models of care for beneficiaries with multiple chronic conditions and that formal measurement of such innovations is critical to quality improvement and to building an evidence base where none now exists.

Currently, CHCS says, consensus is lacking on how to most effectively manage care for adults with three or more chronic conditions. "Adults with multiple chronic conditions have intense and varied care needs, are among Medicaid's highest utilizers, and are among the program's costliest beneficiaries," says CHCS senior vice president Melanie Bella, who led the demonstration project. "Through the Medicaid Value Program (MVP), we were able to shed more light on how to tailor care management strategies to best meet the specific needs of people with multiple serious conditions."

The Medicaid Value Program was the first national effort to examine novel approaches to improve care for adults with multiple chronic conditions. It brought together 10 diverse organizations, including health plans, state Medicaid agencies, provider organizations, and others, to develop and test new strategies for adult Medicaid beneficiaries with multiple chronic conditions.

An evaluation performed by Mathematica Policy Research asked four questions: 1) What interventions did MVP grantees implement and what were they trying to achieve with the interventions? 2) To what extent were MVP grantees successful in implementing their interventions and what factors facilitated or impeded this? 3) Did the interventions achieve the outcomes or impacts sought? If not, why? And if so, how? What factors could have made the interventions more successful? And, 4) How generalizable is the MVP experience? That is, what was learned about the various models as well as their replicability and utility?

Different populations targeted

Target populations for the 10 programs varied, with four grantees targeting patients with diabetes and comorbidities, three focusing on mental health and substance abuse care, and two focusing more generally on those at high risk for adverse events and clients with high overall costs (and multiple chronic medical conditions). The remaining grantee was more methodologically focused on comparative assessment of health risk screening tools to support system redesign.

Of the nine care-focused programs, seven targeted their interventions on patients, with all but one using a case management and coordination model to improve patient care. The exception augmented an existing disease management program with in-person patient education. Two grantees targeted their intervention on providers, in the hopes of improving patient care quality.

Only two interventions ran for less than 12 months. The rest had an average reporting period of 15 months. Two had at least one year of operational experience before the start of MVP.

The evaluators found that grantees generally were able to implement the interventions they sought and create the partnerships needed to support those interventions, although refinements were made in some cases.

Start-up delays were common. Grantees varied in the size of intervention group they aimed for from the start, with two substantially larger than the others. The small size of target populations for many interventions reflected a combination of inherently small numbers of people with certain complex conditions, limited grantee resources, and challenges associated with recruiting for some of the interventions.

Factors influencing success

Evaluators said they identified at least five factors that influenced implementation success in all the programs. First was strong leadership from the top of the organization. Second, grantees succeeded most at implementation in environments where conditions were favorable with no competing priorities or constraints that limited attention and resources for the intervention. Third, buy-in from staff, patients, and providers is critical. Fourth, support and leadership by the Medicaid agency is critical for many grantees to open doors because the agency has authority over program policy and operations. And fifth, the ability to standardize the intervention early on, with highly specified intervention activities and protocol documentation, made it much easier to communicate what was needed and avoid later delays or confusion among those who implemented the interventions.

The evaluators said the replicability of an intervention depends on: 1) the clarity and specificity of intervention activities; and 2) its organizational and environmental context. Most grantees thought their interventions could be replicated and the evaluators tended to agree. But they said the more challenging issue involves whether it makes sense to encourage replication. Grantees generally saw value in encouraging replication even if they were not able to show empirical evidence on outcomes or business returns.

Positive results

On balance, the evaluators said, MVP has been a positive program on several dimensions:

1. From a process perspective, MVP demonstrated the value of using logic models and process measures to help grantees be clearer about their interventions and what they hoped to achieve.

2. MVP generated evidence suggesting that well-conceived efforts to better integrate care across the range of services required by beneficiaries with multiple chronic conditions have promise.

3. The findings show it is not just what the intervention is that matters, but also that the intensity of the intervention is likely to be important to improving outcomes for patients with multiple chronic illnesses.

4. MVP brings to light what could be some difficult or even insurmountable challenges in building a strong empirical evidence base on ways to improve care for adult Medicaid beneficiaries with multiple chronic illnesses.

Arising out of those conclusions are three recommendations:

1. Organizations should favor multifaceted yet well-targeted interventions with sufficient intensity to affect outcomes. The evaluators say the populations targeted by MVP interventions have complex conditions and multiple needs and they are involved with the health care system in a number of ways. It seems important, they say, to focus on interventions, such as the Washington state program, that have the potential to drive change in ways that align processes to reinforce improvements in care and outcomes.

2. Greater emphasis should be put on learning and design before testing. The evaluators found that often changes in care processes were being implemented for the first time or conceived without benefit from existing experience elsewhere. Diversity also limited what grantees could learn from one another or others could learn by examining the collective experience. Given the challenges illustrated by MVP in assessing the effects of interventions, the evaluators say, it would be valuable to spend substantially more time exploring potential interventions for their promise so efforts and tests could be focused on those that are most promising.

3. Multisite tests of the most promising interventions should be considered. Creating change through small-scale interventions that are narrowly focused geographically or defined such that they reach small numbers of people, however sick they are, makes it hard to test interventions, the evaluators say. If there are particularly promising interventions, it could be strategically valuable to focus resources on bringing them to scale for rigorous testing. And beyond the numbers, multisite tests also add insight on an intervention's replicability across sites, especially if there is sufficient data to assess effectiveness at the site level as well as across sites.

Ms. Bella tells State Health Watch a number of core elements of effective care models emerged from the MVP demonstrations, including service integration, particularly around physical and behavioral health; multidisciplinary care teams led by a "go-to" person; and consumer engagement.

Evaluating success not an issue

Problems in measuring success, Ms. Bella says, were not an issue for many of the MVP teams, as seen by the fact that they intend to continue funding the interventions into the future. "Given the dearth of evidence on best practices for managing care for these complex populations, we are finding that limited evidence is often sufficient to engage the interest of other organizations that recognize the need to identify better, or promising, models of care for these consumers," she says.

In an ideal world, Ms. Bella says, the evaluators' three recommendations above would be addressed in unison. She notes that multifaceted interventions aiming to improve quality of care through combinations of strategies at multiple levels hold the greatest promise for improving outcomes. However, she says, many organizations need to start somewhere and should consider incremental approaches to improve quality in addition to more comprehensive, often resource-intensive, approaches that may not always be feasible to implement all at once.

For the Center for Health Care Strategies, she says, the second and third recommendations confirm the strategy for identifying and disseminating best practices for managing care for those populations representing highest needs and highest costs. That strategy has two elements, she says: identifying and testing emerging models of care through pilot demonstrations and, for those models that suggest promise in pilot efforts, implementing larger multisite demonstrations incorporating rigorous evaluations to confirm scalability and to build empirical support for their spread.

Download the Medicaid Value Program report at www.chcs.org. Contact Ms. Bella at (609) 528-8400.