As a small portion of the population accounts for a significant share of healthcare spending, many efforts to reduce costs focus on this group of “high utilizers.” The thought is that, while much of their spending is likely unavoidable, this is where spending is concentrated, so any opportunities to provide care more efficiently can yield significant savings and possibly improve outcomes as well.
A common approach is to place high-utilizing patients into care management programs, which are typically teams of providers from multiple specialties, led by a care manager. An article in the American Journal of Managed Care reviewed recent studies of the effectiveness of these care management programs and found that, while many studies show significant cost savings, the more robust studies concluded that cost savings were “limited or nonexistent.”
The review points to a few possible reasons for limited cost reductions in care management programs. First, many high-utilizers only stay in this category for a short period of time. The conditions causing them to need intensive care may resolve quickly (thus reducing costs), but a study lacking a control group may inappropriately attribute this savings to the care management program. Second, high utilizers suffer from a wide range of conditions and require a wide range of interventions, making it difficult for care management programs to tailor teams meeting each patient’s needs. Additionally, providers working with a care management team may better identify conditions that were previously going untreated. (This may lead to better outcomes, but also higher costs for additional treatments).
For care management programs focusing on high-utilizing patients, it is crucial to select patients with long-term utilization patterns that are driven by the factors most conducive to change. Given the very limited direct evidence suggesting how to accomplish this, care management programs are best served by being kept small and focused on the highest-need patients, who may not necessarily be current high utilizers.
Brent C. Williams in the American Journal of Managed Care
The article also suggests that organizations funding future research on the effectiveness of care management should first prioritize randomized controlled trials, and secondly “nonrandomized studies that measure total population costs over time rather than just costs of intervention and nonrandom comparison groups.”