High-risk veterans in primary care intensive management programs received more outpatient care with no increase in total costs, according to the results of a study published in the Annals of Internal Medicine.

With rising healthcare costs reaching unsustainable levels, effective management of the relatively small population of patients who require the most care and incur the highest healthcare costs is a focus of many providers and payers who are turning to intensive primary care programs to meet the needs of these patients.

Jean Yoon, PhD, MHS, from the US Department of Veterans Affairs Health Economics Resource Center and Center for Innovation to Implementation in Menlo Park, California, and colleagues set out to assess whether augmenting usual primary care with team-based intensive management lowers use levels and costs for high-risk patients (Patient Aligned Care Team [PACT] Intensive Management [PIM] Project; ClinicalTrials.gov identifier NCT03100526).

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The authors randomly assigned 2210 patients from 5 US Department of Veterans Affairs medical centers who were at high risk for hospitalization and who had had a recent acute care episode to either intensive management or usual primary care. The patients (mean age, 63 years; 90% men) had an average of 7 chronic conditions. The primary outcome was healthcare use and costs during the 12 months before and after randomization.

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Only 44% of the patients in the intervention group received the full intensive management, defined as 3 or more encounters in person or by telephone from the intensive management team. Of the remaining patients, 37% could not be contacted or were identified by the intensive management team as unlikely to benefit from the intervention. Another 18% were offered limited services or declined to participate after 1 or 2 encounters. These patients then continued to receive treatment as usual from the primary care team.

Inpatient costs decreased more for the intensive management group than the usual care group (−$2164; 95% CI, −$7916 to $3587), whereas outpatient costs increased more for the intensive management group than the usual care group ($2636; 95% CI, $524-$4748). These cost increases were driven by greater use of primary care, home care, telephone care, and telehealth. However, mean total costs were similar in the 2 groups before and after randomization.

The authors note that the promise of lower costs with more targeted care of high-risk patients has yet to be realized. Nevertheless, the shift in costs from inpatient to outpatient and the overall cost neutrality of the added intensive services suggest there is a potential to improve the way care is delivered. They argue that improvements in the design of intensive management programs are necessary for this approach to reach its potential.


Yoon J, Chang E, Rubenstein LV, et al. Impact of primary care intensive management on high-risk veterans’ costs and utilization. Ann Intern Med. 2018;168:846-854.