Integrated Care Affects Healthcare Use Among Vulnerable Adults

Shippee

Vickery

Providing integrated medical care and social support services led to increased use of primary care among vulnerable adults who were enrolled in a Medicaid accountable care organization (ACO), according to two studies published in Medical Care Research and Review.

One study used Medicaid claims data for about 90,000 enrollees to compare the use of medical services by Hennepin Health (Hennepin County, MN) ACO enrollees to non-ACO Medicaid enrollees in the same geographic area. In the first two years, adjusted results of the claims analysis showed that Hennepin Health enrollees had 11% more primary care visits and 52% more emergency department (ED) visits.

The researchers also found that Hennepin Health had a slight, non-significant decrease in hospitalizations over time, whereas other Medicaid managed care had a significant increase over months in the data. Hennepin Health also had significant decreases in ED and primary care over time, and a significant increase in dental care.

The second study used interview data from 35 Hennepin Health members enrolled for two or more years during the study period. Researchers asked about their lives, challenges, healthcare use, and other topics. They coded and analyzed these data using a process called fuzzy-set qualitative comparative analysis designed to isolate "causal recipes" associated with improved quality of life.

Findings include:

• 66% of ACO members interviewed had a diagnosed mental illness
• 40% had some degree of unstable or subsidized housing
• 20% reported use of shelters or homelessness during the study period
• 60% described a strong, trusting relationship with their primary care provider or care team
• 46% received consistent mental healthcare
• 40% had frequent documented contact from their extended care team (8 to 12 contacts per year)
• 49% could not recall documented contact from their extended care team

“First, compared to other Medicaid managed care, Hennepin Health had higher primary care and ED use overall, and lower hospitalizations but only among high utilizers,” says co-author Nathan D. Shippee, PhD, an associate professor at the University of Minnesota School of Public Health. “As a time trend, however, Hennepin Health had increasing dental use and a non-significant downward trend in hospitalizations; comparisons had significant decreases in dental use and increases in hospitalization. Both groups had significant decreases in ED and primary care visits over time.”

Second, among Hennepin Health enrollees, a strong bond to primary care and behavioral health services were key to improved quality of life among a pretty complex population, according to the study. “Together, these findings suggest that integrated, accountable care can increase use of primary care and other services, which seems important for quality of life, but there was no corresponding decrease in hospital visits-other than the lower rate among high utilizers,” Shippee says.

Important to healthcare executives

“The importance of primary care shouldn't be surprising if we think of historic barriers to accessing care among many populations, but the evidence here indicates that different models of care are actually associated with different levels of primary care use,” Shippee says. “So, aspects of outreach, connection to county services, and other components of Hennepin Health might be a model to consider. In addition, the finding of lower hospitalizations among high utilizers suggests that the model could be targeted to focus on helping people who visit the hospital or ED frequently. Finally, ensuring that a model of care is centered around a strong primary care connection and, likely, behavioral health services, may help people get the help they need and feel better.”

According to co-author Katherine D. Vickery, MD, a family medicine physician and clinical investigator at Hennepin Healthcare, the researchers have seen a lot of evidence on Medicaid expansion generally, as well as internal and pre-post examinations of healthcare use under certain models.

“By contrast, our first study was focused on comparing different plans in Medicaid expansion to see if an ACO model for these very low-income adults would have an impact on healthcare use versus other approaches,” Vickery says. “To the extent that it would, the second study among HH enrollees was designed to see which pieces of the care model, and which people, might derive the most benefit in a patient's life.”

“Also, among other differences, there was higher homelessness and unenrolled months among Hennepin Health's population, which we had to adjust for,” Vickery says.

Vickery has three take away messages for healthcare executives:

• Getting people connected to primary care matters, and some care models (e.g., Hennepin Health) seem to do that better than others.
• Integrated, accountable care has some benefits when compared to other models of care, but finding decreases in acute visits to the ED or hospital may take more time or require tighter targeting.
• Behavioral healthcare and other extended care team components seem to be very important to the Hennepin Health model.