Across the country, Medicaid stakeholders are exploring new ways to address the needs of the program’s highest-utilizing patients. Super-utilizers make up only five percent of the Medicaid universe, yet these patients with complex needs account for more than 50 percent of overall program spending.

This brief offers important insights for states, health plans, and providers looking to improve care delivery for Medicaid’s sickest, costliest patients. Author Thomas Bodenheimer, MD, MPH of the University of California San Francisco reports on a national review of 14 super-utilizer programs undertaken to help guide the San Francisco Health Plan in designing better ways to care for high-risk, hard-to-reach patients. The majority of the programs analyzed involve Medicaid patients, but the review also examined programs for employed individuals and Medicare that offer potential relevance to Medicaid.

The brief outlines 10 key factors for success for high-utilizer complex care management programs and details core features as well as available cost and utilization data for the programs analyzed. While much remains to be done to understand how to best structure care approaches for Medicaid’s high-utilizing patients, the findings in this brief add to the emerging body of evidence regarding high-touch, tailored approaches for this population.

This brief was made possible by Kaiser Permanente Community Benefit, which is also supporting CHCS’ Complex Care Innovation Lab. This national effort is working with pioneering programs across the country to design and spread better ways to care for the highest-need, highest-cost populations in publicly financed care. Three of the programs identified for this analysis — the Camden Coalition, CareOregon, and Hennepin Health — are Innovation Lab participants.