Evaluation of a High Risk Case Management Pilot Program for Medicare Beneficiaries with Medigap Coverage

Research Objective: To evaluate the second year experience of a High Risk Case Management (HRCM) pilot program.

Methods: Nurses and social workers provided in-person, telephonic, and mailed services to improve care coordination from 12/1/2008 to 12/31/2010. Adults (65+ years of age) who resided in one of five pilot states and who had a Hierarchical Condition Category score > 3.74, or were referred into the program were included in the analysis. This included 1,290 members who participated in the program, and 6,811 members who were qualified but did not participate.

Regression analyses were used to estimate healthcare savings and differences in quality of care metrics between engaged program members and similar non-engaged members. Quality of care metrics related to reduced hospital readmissions as well as Evidence Based Medicine (EBM) metrics were evaluated.

Results: Although not statistically significant, 63% of hospital readmission related metrics and 79% of EBM metrics showed engaged members received higher quality of care. The program showed an estimated savings of $1.5 million dollars, but was not statistically significant. Most of these savings were attributable to Medicare.

Conclusions: This study focuses on hospital readmission related metrics for a HRCM program designed solely for Medicare members with Medigap coverage. The HRCM program was associated with higher quality of care; however, the decrease in costs was not statistically significant in the second year of the program.