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'Hotspotting' for Medicaid Patients Lowers Healthcare Spending and Utilization

By Christopher Cheney  
   February 25, 2020

CareMore Health's care management program in Tennessee has multidisciplinary care teams with community health workers, primary care providers, and social workers.

A care management program in Tennessee for high-need, high-cost Medicaid patients reduces healthcare service spending and healthcare utilization, research published this month indicates.

"Superutilizer" patients account for a disproportionate share of healthcare spending in the United States, with earlier research finding that 5% of the country's population accounts for 50% of annual healthcare expenditures. A study published last month by New England Journal of Medicine stirred controversy about care management programs for superutilizer patients—finding that the Camden Coalition of Healthcare Providers "hotspotting" program did not reduce hospital readmissions.

The research published this month, which appears in American Journal of Managed Care, features a care management program for Medicaid patients conducted by CareMore Health in Memphis, Tennessee. The lead author of the CareMore research told HealthLeaders that the NEJM study is a reminder that there is no silver bullet for hotspotting, but he said care management for complex patients should continue.

"The results from our evaluation of CareMore’s complex care management program suggest that carefully designed and targeted programs can improve care and reduce spending for high-need, high-cost patients. Hopefully, this results in a more optimistic view on the potential of hotspotting, and spurs continued work to develop care models that better serve our most complex patients," said Brian Powers, MD, MBA, director of population health strategy and analytics at CareMore.

CareMore research data

The CareMore care management program was staffed with a multidisciplinary team including a community health worker, a social worker, and a primary care provider.

The community health worker conducted patient accompaniment, activation, engagement, and outreach. The social worker conducted counseling and brief interventions for patients with behavioral health needs and coordinated referrals to social service agencies and other medical providers. The PCP conducted comprehensive care for acute and chronic conditions as well as coordination with specialists and inpatient clinicians.

The CareMore research examined data collected from nearly 200 Medicaid patients, with 71 assigned to the care management program and 127 assigned to usual care over a year-long period. The research includes several key data points:

  • Compared to patients receiving usual care, care management program patients had significantly lower total medical expenditures ($7,732 lower per member per year)
  • Care management program patients had 3.46 fewer inpatient bed days per member per year
  • Care management program patients had 1.35 fewer specialist visits per member per year

"A complex care management program reduced spending and inpatient utilization among high-need, high-cost Medicaid patients. Patients randomized to complex care management had [total medical expenditures] that were 37% lower than those randomized to usual care, an absolute reduction of $7,732 per patient per year. This spending reduction appeared to be driven primarily by decreases in inpatient utilization—bed days were reduced by 59% and admissions by 44%," Powers and his co-authors wrote.

Keys to care management success

Powers told HealthLeaders that CareMore's hotspotting program has four essential elements.

  • Target the right patients: CareMore's care management program used predictive models, claims data, clinical criteria, and clinician judgment to identify "rising risk" populations and those most likely to benefit from complex care management, rather than focusing on historical "superutilizers" whose care needs and spending often regress to the mean.
  • Incorporate non-traditional healthcare staff such as community health workers: CareMore's hotspotting program underscored the important role that community-based, non-medical team members play in engaging patients, building trust, and better understanding and managing the non-medical drivers of poor outcomes. For example, the community health worker served as an engagement specialist, creating a safe and welcoming environment for patients and utilizing their training to increase patient motivation and activation. The community health worker also functioned as the engaged family member that many patients lacked. 
  • Integrate within the clinical team: The care management program was built into an existing medical home model. This removed barriers for collaboration and coordination between the community health worker, social worker, and primary care physician. It also allowed the care team to simultaneously address the medical and non-medical drivers of poor outcomes, rather than approaching each in a siloed fashion.
  • Focus on the most impactable drivers of poor outcomes: The hotspotting program tailored complex care management to the needs of individual patients rather than using a one-size-fits-all approach. For each patient, the care team identified and prioritized patients' unique drivers of poor health and high costs, with a focus on the drivers that mattered most to the patient and those that could be addressed over the course of weeks and months. This was essential for improving efficacy and efficiency.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


Compared to patients receiving usual care, CareMore Health's "hotspotting" program reduced total medical expenditures by $7,732 per member per year.

The primary drivers of the spending reduction were lower inpatient utilization, with bed days reduced by 59% and inpatient admissions decreased by 44%.

The care management program had four keys to success such as targeting patients with "rising risk" rather than historical "superutilizers."

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