Intensive Outpatient Program Does Not Cut Costs for High-Need Patients

By Will Boggs MD

NEW YORK (Reuters Health) - An intensive outpatient program to augment primary care does not reduce healthcare costs among high-need Veterans Affairs patients, according to results from a randomized trial.

"Patients in ImPACT (the VA medical home with an Intensive Management program) received substantially more primary care and had very positive experiences with the program, but while the program was cost-neutral (it essentially paid for itself), it did not achieve declines in hospitalization and cost compared with standard care in the VA's patient-centered medical home," said Dr. Donna M. Zulman from Stanford University and VA Palo Alto Health Care System in Menlo Park.

"I think this speaks to how challenging it is to transform these outcomes in a high-risk patient population," she told Reuters Health.

Intensive outpatient care programs have emerged as models for delivering comprehensive, individualized medical, mental health, and social services to high-need patients (sometimes referred to as superutilizers), but evidence regarding their effects on hospitalization and costs is mixed.

Dr. Zulman and colleagues investigated the effects of ImPACT on health care utilization, cost, and patient experience in a randomized trial of 140 patients assigned to ImPACT and 405 patients assigned to PACT (medical home without intensified management).

Among the 54 ImPACT participants who responded to surveys, 96% said they would recommend the program to others and 70% or more reported being "extremely satisfied" with the program's medical care, social work, and recreation therapy and community services.

These patients reported significant increases in mean ratings for satisfaction with VA care and communication, but not for accessibility/convenience, the researchers report in JAMA Internal Medicine, online December 27.

Patients assigned to ImPACT had significantly more primary care visits than those assigned to PACT, but both groups had similar outcomes of other inpatient and outpatient healthcare utilization measures, and mortality rates did not differ significantly between the groups.

Overall, monthly healthcare costs declined at a similar rate among ImPACT patients and PACT patients. ImPACT led to a significant increase in monthly person-level primary care costs, but there were no effects on costs associated with other outpatient or inpatient services.

"This evaluation is one of few randomized trials of intensive outpatient care for complex, high-need patients," Dr. Zulman explained. "The comparable cost declines observed among patients in the program and those receiving standard care illustrate a 'regression to the mean' phenomenon, where individuals who are in the highest percentiles typically move toward the average over time."

"In this evaluation, we observed a decrease in cost of about 20% among patients in the intensive outpatient program," she said. "If we had not had a control group, it would be easy to conclude that the program dramatically reduced costs. However, we observed a similar decrease in cost among patients in the control group. This underscores the importance of rigorous evaluations when studying interventions for high-risk and high-cost patients."

"Intensive outpatient programs may benefit certain patients, but when it comes to implementing a new program, the optimal approach is likely to depend on the local context, population needs, and resources," Dr. Zulman concluded. "It's important to exercise caution, and avoid a one-size-fits-all solution when it comes to redesigning care for high-need patients."

In an accompanying editorial, Dr. Mitchell H. Katz from LA County Department of Health Services, Los Angeles, notes, "Common sense doesn't always prove to be right."

"Preintervention-postintervention observational designs can be mistaken, especially when there is no concurrent control," he writes. "Just as we would not accept a drug as efficacious without a randomized clinical design, quality improvement interventions benefit from rigorous evaluation methodology."

Dr. Gerard Anderson from Johns Hopkins Bloomberg School of Public Health and John Hopkins University School of Medicine in Baltimore, Maryland, who recently reviewed health system performance for high-need patients, told Reuters Health by email, "It is always surprising that we are unable to significantly improve care that we know needs improvement. This is one of many studies that have not shown that a better delivery system provides lower spending."

"We simply do not know how to improve outcomes," he said. "They did most of the things that are recommended."

Dr. Anderson concluded, "The possibility of improvement does exist - we just need to find the correct set of incentives."

Dr. Karandeep Singh from the University of Michigan Medical School, Ann Arbor, has also investigated interventions to address high-need, high-cost populations. He told Reuters Health by email, "If intensive case management does not work when applied broadly, then we need to go back to the drawing board and rethink our paradigm of why patients utilize the health system and the extent to which health care utilization can or should be limited."

"The authors' findings lend support to the idea that patient-centered medical homes (PCMHs) may be beneficial in reducing health care costs and utilization," he said. "While studying PCMHs was not the purpose of the study, it is certainly possible that the authors found no difference in the two arms of the study because PCMHs are so effective that additional interventions may have a negligible impact."

SOURCE: https://bit.ly/2iuptQL and https://bit.ly/2iJ8opq

JAMA Intern Med 2016.

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