Randomized controlled trial of intensive care management for high-cost Medicaid clients with behavioral health needs and multiple chronic conditions

Background: Approximately 5% of Medicaid beneficiaries drive 50% of Medicaid health care spending. Rethinking Care (RTC) is a randomized controlled trial providing community-based, registered nurse-led, multidisciplinary care management to high-cost Medicaid beneficiaries with behavioral health needs and multiple chronic conditions in King County, Washington.

Methods: An intent-to-treat approach and difference-in-differences regression models were used to compare per member per month outcomes up to 24 months post-randomization for individuals randomized to the RTC intervention (n = 557) and to an abeyance group who were offered the intervention at a later date (n = 563). Outcomes included costs and use of services (i.e., medical, long term care, mental health, and alcohol/drug treatment), criminal justice involvement, homelessness, and death. In a sub-analysis, outcomes were compared for those clients who engaged in the intervention (n = 251) to a propensity-score matched comparison group (n = 251). All models were adjusted for age, sex, race/ethnicity and for serious mental illness, risk score, and need for alcohol and drug treatment as measures of health status. Models were also weighted by the number of post-intervention Medicaid eligible member months.

Results: Of those offered the RTC intervention, 51% completed an in‐person comprehensive assessment of medical and social needs and 45% subsequently set at least one health-related goal in collaboration with a nurse care manager. In the intent-to-treat analysis, RTC clients had higher odds of receiving outpatient mental health services, higher prescription drug costs, higher odds of incurring narcotics costs and lower odds of death in the post-period relative to the comparison group. Those who engaged in the RTC intervention, relative to a matched comparison group, had higher outpatient medical costs, higher odds of incurring outpatient mental health costs, lower odds of inpatient admissions, and lower odds of death in the post-period.

Conclusions: Low engagement rates and delayed service onset with subsequently shorter follow-up periods may explain the few differences in outcomes between the intervention and comparison groups. Taken together, results suggest that the RTC intervention may improve access to some health and social services. Furthermore, less expensive outpatient services may serve as substitutes for costly inpatient services in the intervention group. These findings may be applicable to clients who engage in other start-up, care management programs targeted to hard-to-reach populations with a high prevalence of addiction, serious mental illness and other chronic conditions.