Targeting Medicaid Super-Utilizers To Decrease Costs And Improve Quality

The Medicaid program serves as the county’s largest insurer, covering over 62 million Americans.i The Center for Medicaid and CHIP Services (CMCS) is committed to supporting innovative care delivery models with potential to improve care, improve health, and reduce costs.

Programs that target “super-utilizers” – beneficiaries with complex, unaddressed health issues and a history of frequent encounters with health care providers – demonstrate early promise of realizing these goals for Medicaid populations. CMCS is issuing this Informational Bulletin to share details of care delivery and payment models to help states and Medicaid providers better meet the complex needs of the highest utilizers of acute care in Medicaid populations.

Section I of this Bulletin describes the key policy decisions that states and providers with existing super-utilizer programs under Medicaid have considered in designing and implementing their programs. It presents a spectrum of possible approaches to address each policy decision based on interviews with state Medicaid officials and providers leading ten super-utilizer programs across the country. Section II provides details of existing Medicaid funding mechanisms and policies that can support super-utilizer programs.

As noted, this informational bulletin is based on interviews with ten super-utilizer programs, including six described in detail in the appendix. CMCS identified these programs based on conversations with CMS and HHS staff, program leaders, foundations, state Medicaid agencies, and outside experts. We appreciate that there are other programs and successful models and invite others to share their experiences and insights with us.

The case studies identified in this round of conversations were primarily oriented towards acute care. Most are not in capitated arrangements, although several programs have some intersection with managed care. We believe that super-utilizer programs also hold strong promise to address the needs of complex Medicaid beneficiaries in long term care settings and in managed care settings, but this informational bulletin summarizes our learning to date. We will continue to refine and develop the lessons on these issues and welcome feedback.

Interest in super-utilizer programs is increasing across the public and private sectors, creating new funding opportunities to support these programs. The Center for Medicare and Medicaid Innovation (CMMI) awarded Health Care Innovation Awards to two initiatives targeting Medicaid super-utilizers. Cooper University Hospital in New Jersey was awarded $2.8 million to expand the Camden Coalition super-utilizer program to serve over 1200 patents with estimated 3-year cost savings of $6.2 million. Rutgers, the State University of New Jersey, was awarded $14.4 million to test community-based super-utilizer models led by safety-net provider organizations in Pennsylvania, Colorado, Missouri, and California with estimated 3-year cost savings of $67.7 million. The first annual report for these CMMI awards will be in 2014. In addition, the Robert Wood Johnson Foundation is funding super-utilizer programs in six communities in New Jersey, Ohio, Maine, California, Massachusetts, and Michigan. These programs include community-based super-utilizer teams that focus on the highest utilizers in a specific geographic area and super-utilizer clinics/ambulatory Intensive Care Units (ICU) that care for patients with the highest utilization.

We look forward to continuing to work with states, providers, and other stakeholders to provide further assistance in developing new care models to improve quality and decrease costs for complex Medicaid beneficiaries. Please contact Stephen Cha, Chief Medical Officer at CMCS, at for questions about this Bulletin or to suggest additional resources or care models.

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