Cost, Utilization, and Quality of Care: An Evaluation of Illinois’ Medicaid Primary Care Case Management Program

Robert L. Phillips; Meiying Han; Stephen M. Petterson; Laura A. Makaroff; Winston R. Liaw

doi:10.1370/afm.1690

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Figure 1
IHC and YHP Adjusted per-member-per-month cost trends.

IHC = Illinois Health Connect; YHP = Your Healthcare Plus; PMPM = Per member per month.

Note: IHC costs prior to 2006 are estimated based on costs for enrolled Medicaid patients who would have met IHC eligibility requirements.
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Figure 2
Change in average Medicaid per-member-per-year costs for illinois and comparison states.

Note: Data used to construct this figure were taken from Center for Medicare and Medicaid Services Statistical Supplemental files Table 13.27 for 2004–2009 for each of 5 states that had some mix of managed care and primary care case management; 2004 was used as the reference year.

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Table 1

Features of Illinois Health Connect

1.7 Million beneficiaries in 2010 (includes YHP patients in IHC); every beneficiary required to select a primary care clinician^a

Monthly care management fees: $2 for children, $3 for adults, $4 for disabled or elderly beneficiaries^a

Pediatric claims paid within 30 days; adult claims paid within 60 days

Quarterly academic detailing about the administration of the program and clinical care of the patient population for primary care clinicians

Multiple online tools such as registries and report cards to assist clinicians with population-based management^b

IHC providers required to make preventive care available within 5 weeks of request (or 2 weeks for infants younger than 6 months), urgent care appointments within 24 hours, appointments for non-serious complaints within 3 weeks, and follow-up visits within 7 days of discharge from an emergency department or hospital^a

Practices required to provide and coordinate maternal and child health services^a

Practices required to institute an action plan for enrollees with chronic diseases^a

Quality-based bonus payments^a

IHC = Illinois Health Connect; YHP = Your Healthcare Plus.
↵a Features common in patient-centered medical homes.
↵b Features common in accountable care organizations.

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Table 2

Study Cohort Demographics in Illinois Medicaid Programs

	2006				2010

	Medicaid	IHC-Eligible	YHP-Enrolled	Other^a	Medicaid	IHC-Eligible	YHP-Enrolled	Other^a
Beneficiaries, No.^b	2,095,699	1,178,192	276,403	641,104	2,692,123	1,624,370	388,566	679,187
Study cohorts data^c
Study cohorts, No.	1,883,462	1,021,081	260,163	602,218	2,433,840	1,388,134	363,411	682,295
Age, %
0–5 y	19.8	27.0	20.2	7.6	19.1	25.5	17.6	6.7
6–18 y	35.5	42.9	24.7	27.6	38.3	45.8	33.5	25.6
19–40 y	22.0	23.2	27.3	17.7	21.0	21.3	25.4	18.2
41–64 y	14.2	5.9	27.4	22.4	14.0	6.7	23.3	23.8
65+ y	8.5	0.9	0.4	24.8	7.7	0.9	0.3	25.6
Race/ethnicity, %
Non-Hispanic white	39.9	36.4	38.1	46.6	40.5	37.3	38.7	47.9
Non-Hispanic black	30.7	27.7	37.7	32.9	26.1	22.0	33.3	30.5
Hispanic	20.7	26.3	17.8	12.5	24.2	30.5	21.1	13.1
Other race^d	8.6	9.6	6.5	7.9	9.2	10.2	6.9	8.5

IHC = Illinois Health Connect; YHP = Your Healthcare Plus.
↵a Includes mainly beneficiaries enrolled in both Medicare and Medicaid (the dual eligibles).
↵b Beneficiaries after the exclusion of infants younger than 90 days.
↵c Study cohorts after the exclusion of individuals in managed care organizations, infants aged younger than 90 days, and YHP institutionalized populations.
↵d Includes Asian, Pacific Islander, etc.

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Table 3

Net Differences Between Actual Yearly Costs and Predicted Yearly Costs, Illinois Medicaid, 2007–2010

Year	Medicaid, Total, $	IHC, $	YHP, $	Other Medicaid, $
2007	−47,072,646.67	−1,838,125	−57,634,125	112,149,447
2008	−38,298,925.40	−55,081,415	−126,088,637	172,494,703
2009	−238,670,125.40	−33,066,300	−131,242,863	−100,954,005
2010	−1,132,820,583.00	−147,049,605	−202,844,218	−766,382,363
Net Total	−1,456,862,280.47	−237,035,445	−517,809,842	−582,692,218

IHC = Illinois Health Connect; YHP = Your Healthcare Plus.

Note: The categorical savings do not add up to total Medicaid because of the program distribution change.

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Table 4
Changes Within Selected Illinois Medicaid Cost Categories, 2010 vs Projected
Cost Category Medicaid IHC YHP Other
Clinic, % 32.57 45.70 24.89 13.48
Inpatient, % −30.27 −22.66 −24.17 −32.27
Prescription, % −9.88 −5.48 0.65 −19.44

IHC = Illinois Health Connect; YHP = Your Healthcare Plus.

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Table 5

Quality Measure Changes 2007–2010 for Illinois Health Connect Patients

Quality Measure	Year	Appropriately Treated, %	Change, %
Diabetes nephropathy screen	2007 2010	80.4 87.5	8.9
Diabetes annual Hemoglobin A_1c	2007 2010	63.9 78.9	23.4
Diabetes retinal eye examination	2007 2010	26.0 39.5	51.7
Any annual well-child visit	2007 2010	81.0 89.5	10.5
Ischemic vessel disease with annual lipid profile	2007 2010	50.6 68.1	34.7
Mammogram	2007 2010	13.6 25.5	87.4
Postacute myocardial infarction taking β-blocker	2007 2010	70.7 61.1	−13.7
Asthma control medication	2007 2010	47.1 50.0	6.2
Cervical cancer screening	2007 2010	13.2 21.9	65.7
Colonoscopy	2007 2010	4.8 8.6	77.2

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In Brief

Cost, Utilization, and Quality of Care: An Evaluation of Illinois' Medicaid Primary Care Case Management Program

Robert L. Phillips, Jr , and colleagues

Background Illinois was an early leader in comprehensive Medicaid reform. In 2006, the state implemented a primary care case management program, Illinois Health Connect (IHC) and a disease management program, Your Healthcare Plus (YHP). The programs aimed to promote preventive care, reduce the redundancy of services through continuity of care with a primary care clinician, and improve the management of chronic diseases.

What This Study Found An analysis of claims and enrollment data from the Illinois Medicaid experiment between 2006 and 2010 finds the programs were associated with cost reductions, improved utilization patterns and generally improved quality. IHC and YHP were associated with 1) substantial increases in outpatient services; 2) larger decreases in inpatient and emergency services; 3) a reduction of total costs vs. projections; and 4) substantial improvements in most preventive and chronic care measures. Illinois Medicaid expanded considerably between 2004 (1,878,931 enrollees) and 2010 (2,705,291 enrollees). By the fourth year, the estimated rate of annual savings was 6.5 percent for IHC and 8.6 percent for YHP, with a cumulative Medicaid savings of 1.46 billion. Per-beneficiary annual costs fell in Illinois over the study period compared to those in states with similar Medicaid programs. Moreover, quality improved for nearly all metrics under IHC, and most prevention measures more than doubled in frequency. Medicaid inpatient costs fell by 31 percent and outpatient costs rose by 25 percent to 46 percent. Avoidable hospitalizations for IHC fell by nearly 21 percent and bed-days by nearly 16 percent. By 2010, emergency department visits declined by 5 percent.

Implications

Although these results are robust and encouraging, the limited evaluation design calls for caution in making causal inferences.
The authors advise interstate collaboration to help states learn from each other.