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Care Coordination Challenges Among High-Needs, High-Costs Older Adults in a Medigap Plan
Timothy S Wells1, Gandhi R Bhattarai, Kevin Hawkins
1Timothy S. Wells, PhD, has been a health services researcher since 2011. Dr Wells has authored 60 peer-reviewed articles. Before joining Optum, Dr Wells worked for the Henry M. Jackson Foundation, and served 23 years as a public health professional in the United States Air Force. Gandhi R. Bhattarai, PhD, is a senior health economics researcher with more than 10 years of experience in designing and implementing various economic, health outcome research and development projects. He has published numerous peer-reviewed articles, and regularly presents his work at professional meetings. He also served as a reviewer for several journals. Kevin Hawkins, PhD, has more than 20 years of experience leading health services research. He has conducted a variety of research and evaluation projects, specifically health-economic, quality-of-life, disease burden, pharmacoeconomics, and retrospective database analyses. Dr. Hawkins has authored more than 100 peer-reviewed articles and presentations, and is a reviewer for several medical-scientific journals. Yan Cheng, MS, is a health economics researcher with extensive experience working with survey data and medical claims data. Recently, her work has focused on health and cost outcomes. Her experience includes using linear and nonlinear statistical models to estimate program impacts on cost and utilization trends. Joann Ruiz, RN, MPH, is the Director of Clinical Programs for UHG Alliances Health Products and Services, and has more than 25 years of experience with clinical programs to improve the health care for people with multiple chronic conditions and/or disabilities. She is also a certified case manager. Cynthia A. Barnowski, RN, MBA, MS, is Vice President for UHG Alliances Health Products and Services. She has more than 25 years of experience developing, implementing, and managing clinical programs to improve the health care experience and quality of care for people with multiple chronic conditions and/or disabilities. Barney Spivack, MD, FACP, CMD, is National Medical Director, Medicare Case & Condition Management at Optum, and is a clinical geriatrician providing medical director support to the AARP-SHIP MyCarePath program. His most recent academic appointment was as Associate Clinical Professor at the Columbia University College of Physicians and Surgeons. Charlotte S. Yeh, MD, serves as Chief Medical Officer of AARP Services Incorporated (ASI). ASI is a wholly owned, taxable subsidiary of AARP, managing products and services offered as benefits to AARP's 39+ million members. Dr. Yeh leads changes in health care delivery that result in enhanced care for older adults.
Purpose Of The Study:
Many adults 65 years or older have high health care needs and costs. Here, we describe their care coordination challenges.
Primary Practice Setting:
Individuals with an AARP Medicare Supplement Insurance plan insured by UnitedHealthcare Insurance Company (for New York residents, UnitedHealthcare Insurance Company of New York).
Methodology And Sample:
The three groups included the highest needs, highest costs (the "highest group"), the high needs, high costs (the "high group"), and the "all other group." Eligibility was determined by applying an internally developed algorithm based upon a number of criteria, including hierarchical condition category score, the Optum ImpactPro prospective risk score, as well as diagnoses of coronary artery disease, congestive heart failure, or diabetes.
Results:
The highest group comprised 2%, although consumed 12% of health care expenditures. The high group comprised 20% and consumed 46% of expenditures, whereas the all other group comprised 78% and consumed 42% of expenditures. On average, the highest group had $102,798 in yearly health care expenditures, compared with $34,610 and $7,634 for the high and all other groups, respectively. Fifty-seven percent of the highest group saw 16 or more different providers annually, compared with 21% and 2% of the high and all other groups, respectively. Finally, 28% of the highest group had prescriptions from at least seven different providers, compared with 20% and 5% of the high and all other groups, respectively.
Implications For Case Management Practice:
Individuals with high health care needs and costs have visits to numerous health care providers and receive multiple prescriptions for pharmacotherapy. As a result, these individuals can become overwhelmed trying to manage and coordinate their health care needs. Care coordination programs may help these individuals coordinate their care.
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