# Care Coordination for High-Need, High-Cost Commercially Insured Patients: A Randomized Clinical Trial

## TL;DR

A large study found that a national care coordination program did not reduce healthcare costs or emergency visits for high-need, high-cost patients.

## Contribution

This is one of the largest randomized trials evaluating care coordination's impact on healthcare utilization and cost in a commercially insured high-need population.

## Key findings

- No significant differences in emergency department visits or hospital admissions between intervention and control groups.
- Total healthcare costs were similar in both groups over 12 months.
- Results highlight challenges in improving care efficiency for high-need, high-cost patients.

## Abstract

Can a national care coordination intervention reduce acute care utilization and health care cost in a commercially insured high-need, high-cost population?

In this randomized clinical trial including 93 379 adults, there were no differences over 12 months in emergency department visits, hospital admissions, or total cost between patients randomized to the intervention or to usual care.

This large-scale care coordination intervention was ineffective in reducing cost or acute care utilization, which underscores the significant challenges of improving care efficiency in a complex high-need, high-cost population.

This randomized clinical trial evaluates whether a care coordination intervention reduces health care cost and acute care utilization among high-need, high-cost commercially insured patients.

High-need, high-cost (HNHC) patients account for 5% of the US population yet represent nearly half of health care spending.

To evaluate whether national care coordination could reduce health care cost and utilization in a commercially insured HNHC population.

This national, 2-arm randomized clinical trial with intention-to-treat and instrumental variable analyses included patients aged 18 years or older who were defined as HNHC according to a proprietary model (in the top 5% of spend within a rolling 12-month claims utilization window and projected to remain in the top 5% over the subsequent 12 months). Patients were randomized from January 2018 to October 2019. Data were analyzed from January 1 to December 31, 2024.

Participants were randomized monthly 60:40 to telephonic care coordination from a registered nurse, including medication review, a barriers-to-care survey, addressing urgent coordination needs (eg, patient unable to fill prescriptions), development of a case management plan addressing identified clinical risk factors, and establishing an outreach time frame, or to the control group with usual care. The nurse contacted patients over the 60 days after enrollment until all risk factors included in the management plan were addressed.

The main outcomes were mean monthly emergency department visits, inpatient hospitalizations, and total plan cost (medical and pharmacy) over 12 months following the index date, defined as the enrollment date for intervention participants or the randomly generated synthetic enrollment date for nonparticipants. Outcomes were examined separately among patients with diabetes.

The analytic sample included 93 379 HNHC patients with a mean (SD) age of 46 (12) years (54% female). In intention-to-treat analyses, there were no differences between groups in mean (SE) monthly emergency department visits (0.033 [0.001] for control vs 0.033 [0.001] for treatment; mean difference [SE], 0 [0]; 95% CI, −0.001 to 0.002; P = .69), inpatient hospitalizations (0.009 [0] for control vs 0.010 [0] for treatment; mean difference [SE], 0.001 [0]; 95% CI, 0-0.002; P = .06), or cost (total: $2507 [$32] for control vs $2568 [$26] for treatment; mean difference [SE], $60 [$41]; 95% CI, −$20 to $140; P = .14). In the instrumental variable analyses and in the subsample with diabetes, no evidence of statistically significant reductions in these outcomes were found.

In this randomized clinical trial of a national care coordination intervention, neither health care cost nor acute care utilization was reduced in the intervention group compared with the control group. The results emphasize the challenges of improving efficiency of care in a complex HNHC population with escalating health care costs.

ClinicalTrials.gov Identifier: NCT04415515