Approximately 5 percent of Medicaid beneficiaries drive up to 50 percent of total spending in states across the country. More than 80 percent of these high-cost beneficiaries have three or more chronic conditions, and up to 60 percent have five or more; yet, the majority of these patients receive fragmented and uncoordinated care often leading to unnecessary and costly hospitalizations and institutionalizations.
Rethinking the way states care for Medicaid's highest-need, highest-cost beneficiaries presents a compelling opportunity to improve care and control costs. The Rethinking Care Program was developed by the Center for Health Care Strategies (CHCS) to serve as a national "learning laboratory" to design and test better approaches to care for high-opportunity beneficiaries. The initiative is linking state pilot demonstrations with a national learning network committed to advancing Medicaid's capacity to serve these beneficiaries. Program components are described below:
Integrated Care Collaboratives: Through the Rethinking Care Program, CHCS is working with state-led multistakeholder collaboratives to design and test new care management interventions for their highest-need, highest-cost beneficiaries. The goal is to promote strategies to better care for the top 5-20 percent of Medicaid beneficiaries whose care needs account for a significant portion of Medicaid expenditures. State pilot projects are designed to: 1) identify patients who are most likely to benefit from enhanced care management; 2) develop tailored care management interventions; and 3) rigorously measure quality and cost outcomes. Pilots are currently under way in four states.
National Learning Network: Solving the quality and cost conundrum for high-opportunity Medicaid beneficiaries requires regional innovation and national attention. The Rethinking Care Program is convening a national network of leading health care and policy experts to build consensus on rapid cycle testing of new models and tools to develop the evidence base in terms of both quality and costs. These national experts are working with CHCS to analyze the policy and administrative barriers to innovation and identify ways to realign financing to support quality improvement.
Colorado Medicaid is working with two health plans, Colorado Access and Kaiser Permanente, to provide enhanced care management to the state's highest-cost, highest-risk adults with multiple chronic conditions. Approximately 2,000 beneficiaries have enrolled in the Colorado Access pilot since its launch in June 2008. Kaiser Permanente began enrollment in June 2009 and has roughly 800 beneficiaries enrolled.
New York Medicaid is implementing six regional demonstration pilots that are testing an interdisciplinary model of care to improve health care quality, ensure appropriate use of services, improve clinical outcomes, and reduce the cost of care for beneficiaries with medically complex conditions. The pilots are based in New York City, Long Island (Nassau County), Western Region (Erie County), and Westchester County.
Pennsylvania's Medical Assistance program is seeking to integrate physical and behavioral health services for adults with serious mental illness and physical health comorbidities within two regional pilot projects. The pilots are pairing a physical health managed care organization (MCO) with their respective county behavioral health MCO. The pilots are each seeking to enroll up to 10,000 beneficiaries.
Washington Medicaid is providing intensive care management and care coordination for adults with chronic physical needs and mental illness or substance abuse issues. King County Care Partners, a partnership of King County Aging and Disability Services, Harborview Medical Center, and four community health center networks, is coordinating the initial Seattle area pilot for approximately 500 fee-for-service beneficiaries. Enrollment began in February 2009. A second Washington State pilot is being planned to explore working with select community mental health centers to identify patients who need assistance managing chronic medical conditions.