Health Policy Journal Club, Health Policy, Administration & Operations, Social EM

Health Policy Journal Club: Null Results and Next Steps

How do we decrease health care costs among those with the highest utilization?

In the United States, 50% of health care costs are accumulated by only 5% of the population. To curb health care spending, programs have been developed to improve outcomes in patients with high health care use, with mixed results.

The Camden Coalition's Camden Core Model (CCM) is one program designed to improve coordination of care and navigation of our complex health systems with the goal of reducing frequent admissions and associated costs. Early results were promising, but a randomized evaluation found that readmission rates were not significantly reduced. The goal of the present study was to determine why the program had null results.

The authors recruited 800 patients in Camden, NJ, who had been admitted to the hospital in the prior 6 months and met certain "measures of complexity." Measures of complexity included having 5 or more prescriptions, lacking social support, having unstable housing, or having co-morbid mental health or substance use disorders. The patients were randomized to receive usual care or the CCM at discharge. Patients assigned to CCM received services including home visits, medication management, scheduling of and accompaniment to appointments, and connection to community resources. They then used Medicaid and billing data to evaluate the rates of outpatient follow-up and hospital readmission.

CCM did meet its primary goal of increasing ambulatory care visits. The treatment group were more likely to attend a follow-up appointment within 14 days of discharge than the control group (42.35% vs 27.14%) and had on average 0.7 more primary care visits within 1 year of discharge. Despite increased ambulatory visits, readmission rates were essentially unchanged (62.34% of the treatment group vs 61.7% of the control group were readmitted within 180 days). The study results had similar findings for emergency department visits.

Patients with high health care utilization generally have complex medical and social needs. These patients frequently face challenges associated with substance use disorders, mental illnesses, unstable housing, and discrimination in addition to their other medical conditions. While many programs aim to improve outpatient care coordination, the results of this study imply that this is not sufficient to reduce readmission rates in this complex patient population. CCM proponents express that "short-term care coordination could never address decades of trauma, complexity, and deprivation." Though the evaluation found null results, there is still information to gain.

These results emphasize the importance of addressing support of high-need patients beyond direct medical care such as providing housing and legal assistance.

Finkelstein A, Cantor JC, Gubb J, Koller M, Truchil A, Zhou RA, Doyle J. The Camden Coalition Care Management Program improved intermediate care coordination: a randomized controlled trial. Health Aff (Millwood). 2024;43(1):131-139.

Background: When a randomized evaluation finds null results, it is important to understand why. We investigated two very different explanations for the finding from a randomized evaluation that the Camden Coalition's influential care management program—which targeted high-use, high-need patients in Camden, New Jersey—did not reduce hospital readmissions. One explanation is that the program's underlying theory of change was not right, meaning that intensive care coordination may have been insufficient to change patient outcomes. Another explanation is a failure of implementation, suggesting that the program may have failed to achieve its goals but could have succeeded if it had been implemented with greater fidelity.

To test these two explanations, we linked study participants to Medicaid data, which covered 561 (70%) of the original 800 participants, to examine the program's impact on facilitating postdischarge ambulatory care—a key element of care coordination. We found that the program increased ambulatory visits by 15 percentage points after 14 days post-discharge, driven by an increase in primary care; these effects persisted through 365 days.

These results suggest that care coordination alone may be insufficient to reduce readmissions for patients with high rates of hospital admissions and medically and socially complex conditions.

EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care physicians, and the lack of mental health services - are universal problems. As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.  

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