Rethinking eligibility, beyond cost and utilization, offers a more equitable approach to identify high-need individuals for care management.
Care management programs often rely on health care utilization data and costs to identify individuals with high needs. This method can miss underserved groups who experience disparate barriers to care, including communities of color, and also risks perpetuating health disparities. The authors of this brief conducted a literature review and interviews with experts to develop a set of considerations to strengthen equitable population identification. It was developed to inform implementation of CalAIM, California’s initiative to transform Medicaid, but offers takeaways for stakeholders nationally.
The authors describe how using health care utilization and related costs data to identify eligibility for care management programs may not capture the full picture of individuals with high needs. People who might be missed, for example, include individuals with serious behavioral health conditions who do not have chronic physical needs or people experiencing homelessness who infrequently use health care services. The authors describe how relying solely on utilization and cost data can reinforce racial health disparities, for example, by overlooking the barriers to care that Black patients experience. Applying more nuanced identification factors, including examining underutilization of health care services, gathering data from more sources (including outside health care), and monitoring the individuals being identified through an equity lens can help build a more complete picture of members with high needs.
Stakeholders developing or supporting care management programs for adults with complex health and social needs should recognize where bias may exist and develop strategies to address potential disparities in identification, including by using a wider range of data to define eligibility and carefully monitoring efforts with a focus on racial equity. This brief can inform stakeholders nationally seeking to develop nuanced and inclusive approaches for identifying individuals most in need of care and services.