Community Care Management Across the Continuum: Study Results From a Medicare Health Maintenance Plan

Abstract

A large national health plan piloting a community care management (CCM) model for its high-risk, chronically ill, Medicare population has demonstrated a significant reduction in overall medical costs for its participants. The key elements include: the proactive identification and risk stratification of members; assignment of advanced practice nurses to physicians with high-volume high-risk members; and ongoing clinical management across the continuum, establishing a continuous relationship with the member. The results are derived from a retrospective study comparing 6 months of claim data prior to the member entering CCM, with 6 months of claim data while participants received community, care management. Members in the pilot study experienced both a 42% reduction in institutional days and a 53% reduction in admissions to acute care settings. In addition, physician and specialists fees were reduced by 37%. This resulted in a 6-month net savings of $3,602 per participant. To be extremely conservative, the savings were reduced by 50% to reflect the possible impact of regression to the mean. Even accounting for this, the program's projected cost savings are $1,801 per participant in 6 months. The total projected savings for community care managed members in a fully implemented program divided by the entire enrolled population of 27,000 is $6.60 per member per month (PM/PM). The results of this study of care management across the continuum signal a new approach for medical management at a time when health care and the needs of the population are changing.