Outpatient complex case management: health system-tailored risk stratification taxonomy to identify high-cost, high-need patients

Background: U.S. health systems, incentivized by financial penalties, are designing programs such as case management to reduce service utilization among high-cost, high-need populations. The major challenge is identifying patients for whom targeted programs are most effective for achieving desired outcomes. Objective: To evaluate a health system’s outpatient complex case management (OPCM) for Medicare beneficiaries for patients overall and for high-risk patients using system-tailored taxonomy, and examine whether OPCM lowers service utilization and healthcare costs. Design: Retrospective case-control study using Medicare data collected between 2012 and 2016 for Ochsner Health System. Participants: Super-utilizers defined as Medicare patients with at least two hospital/ED encounters within 180\ua0days of the index date including the index event. Intervention: Outpatient complex case management. Main Measures: Propensity score-adjusted multivariable logistic regression analysis was conducted for primary outcomes (90-day hospital readmission; 90-day ED re-visit). A difference-in-difference analysis was conducted to examine changes in per membership per month (PMPM) costs based on OPCM exposure. Key Results: Among 18,882 patients, 1197 (6.3%) were identified as “high-risk” and 470 (2.5%) were OPCM participants with median enrollment of 49\ua0days. High-risk OPCM cases compared to high-risk controls had lower odds of 90-day hospital readmissions (0.81 [0.40–1.61], non-significant) and lower odds of 90-day ED re-visits (0.50 [0.32–0.79]). Non-high-risk OPCM cases compared to non-high-risk controls had lower odds of 90-day hospital readmissions (0.20 [0.11–0.36]) and 90-day ED re-visits (0.66 [0.47–0.94]). Among OPCM cases, high-risk patients compared to non-high-risk patients had greater odds of 90-day hospital readmissions (4.44 [1.87–10.54]); however, there was no difference in 90-day ED re-visits (0.99 [0.58–1.68]). Overall, OPCM cases had lower total cost of care compared to controls (PMPM mean [SD]: − $1037.71 [188.18]). Conclusions: Use of risk stratification taxonomy for super-utilizers can identify patients most likely to benefit from case management. Future studies must further examine which OPCM components drive improvements in select outcome for specific populations