In California, and states across the nation, care management programs traditionally use health care utilization — typically emergency department visits and inpatient admissions — and related costs to identify people with high needs. Yet this approach risks missing people with high needs who may not use services. Indeed, studies show that Black, Latino/x, American Indian and Alaska Native, and other members of underserved groups may not access health care as much as they need to, which can result from factors such as mistrust of health care providers and limited health care services in under-resourced communities. This concern, among others, highlights why relying on utilization data alone may perpetuate inequities and overlook key populations.
This brief, made possible by the California Health Care Foundation, explores the implications of relying on utilization and cost data to identify people with high needs for care management and supportive services. With a focus on CalAIM, California’s initiative to transform Medicaid, it highlights why relying on these data alone may perpetuate inequities, offers considerations for refining eligibility criteria, and shares insights for ensuring that services are provided in a way that is both equitable and impactful. The brief, developed by the Center for Health Care Strategies with Rachel Davis Consulting, draws on a literature review and interviews with national and local experts to outline strategies for identifying high-need populations. While geared toward the California landscape, this resource can inform stakeholders in other states seeking to develop nuanced and inclusive approaches for identifying individuals most in need of care and services.