HealthCore, Inc., 123 Justison Street, Wilmington, DE, 19801, USA.
Adm Policy Ment Health. 2022 Jul;49(4):658-669. doi: 10.1007/s10488-022-01190-6. Epub 2022 Feb 7.
Wraparound programs that provide comprehensive evidence-based outpatient treatment, transportation, social services, and housing supports have shown promise for improving clinical behavioral health-related outcomes to reduce the need for institutionalized care; however, the majority of evidence is based on wraparound programs for children. This study examined the impact of a wraparound program for adult Medicaid managed care organization members with serious mental health or substance use disorders on health care costs and utilization. This retrospective observational study used 2013-2018 claims data collected from a large Medicaid managed care organization operating in multiple states. We used an intention-to-treat difference-in-difference study design to examine the association of the wraparound with costs and utilization. Adult Medicaid members with an emergency department (ED) or inpatient visit for a behavioral health condition (index visit) were eligible for the study. Outcomes included all-cause and behavioral health-related costs and utilization during follow-up after the index visit's admission date. Outcomes were calculated overall, as well as separately by inpatient, ED, and outpatient/wraparound settings. We found that during the first post-admission month, the wraparound program was associated with 27.6 percentage points (PP) and 27.2 PP reductions in the number of behavioral health-related inpatient nights and costs, respectively. However, during subsequent months (median follow-up ranging from 7 to 10 months) there were no associations with per-member-per-month total all-cause or behavioral health-related costs. Nonetheless, the wraparound program was associated with 12.3 PP reduction in all-cause cost during the entire study period among a subset of members who were high cost at the baseline. Reduced hospital utilization and costs during the first month of wraparound services were fully counteracted by outpatient, housing, and other wraparound services costs during the following months. This indicates the importance of proper payment arrangements with value-based contracting or performance targets with wraparound services providers to align the objective of reducing inpatient use. Future wraparound programs may consider a more focused recruitment from high-cost members with complex care needs. However, our estimates were conservative given that it's from a single Medicaid managed care organization's perspective and some benefit from investing in addressing social needs may be realized in longer term (beyond our study period). States' Medicaid programs may consider the longer-term cost and broader, societal benefit of wraparound investment.
环绕式计划提供全面的循证门诊治疗、交通、社会服务和住房支持，已显示出改善临床行为健康相关结果以减少对机构化护理需求的希望；然而，大多数证据都基于儿童环绕式计划。本研究调查了一项针对有严重精神健康或物质使用障碍的成年医疗补助管理式医疗组织成员的环绕式计划对医疗保健成本和利用的影响。这项回顾性观察性研究使用了 2013 年至 2018 年从一家在多个州运营的大型医疗补助管理式医疗组织收集的索赔数据。我们使用意向治疗差异中的差异研究设计来检查环绕式计划与成本和利用之间的关联。有急诊室（ED）或因行为健康状况住院（索引就诊）的成年医疗补助成员有资格参加该研究。结果包括索引就诊入院日期后的随访期间的全因和行为健康相关成本和利用。结果总体计算，以及分别按住院、ED 和门诊/环绕式计划设置计算。我们发现，在入院后的第一个月中，环绕式计划分别与行为健康相关住院夜数和成本减少 27.6 个百分点（PP）和 27.2 PP。然而，在随后的几个月中（中位随访时间从 7 到 10 个月），与每个成员每月的全因或行为健康相关成本均无关联。尽管如此，在基线时成本较高的一部分成员中，环绕式计划在整个研究期间与全因成本减少 12.3 PP 相关。在环绕式服务的第一个月中减少的医院利用和成本在随后的几个月中被门诊、住房和其他环绕式服务成本完全抵消。这表明与环绕式服务提供者建立基于价值的合同或绩效目标进行适当的支付安排对于实现减少住院使用的目标非常重要。未来的环绕式计划可能会考虑从有复杂护理需求的高成本成员中进行更有针对性的招募。然而，鉴于这只是从单个医疗补助管理式医疗组织的角度出发，并且从长期来看（超出我们的研究期间）可能会实现对解决社会需求的投资回报，因此我们的估计是保守的。各州的医疗补助计划可能会考虑环绕式投资的长期成本和更广泛的社会效益。
