Impact on Health Care Utilization and Costs of a Medicaid Community Health Worker Program in Detroit, 2018-2020: A Randomized Program Evaluation

Abstract

Objectives. To compare health care utilization and costs between beneficiaries randomly assigned to usual services versus a community health worker (CHW) program implemented by 3 Medicaid health plans. Methods. From February 2018 to June 2019, beneficiaries residing in Detroit, Michigan's Cody Rouge neighborhood with more than 3 emergency department (ED) visits or at least 1 ambulatory care‒sensitive hospitalization in the previous 12 months were randomized. CHWs reached out to eligible beneficiaries to assess their needs and link them to services. We compared ED and ambulatory care visits, hospitalizations, and related costs over 12 months. Results. In intention-to-treat analyses among 2457 beneficiaries, the 1389 randomized to the CHW program had lower adjusted ratios of ED visits (adjusted rate ratio [ARR] = 0.96; P < .01) and ED visit costs (ARR = 0.96; P < .01), but higher adjusted ratios of ambulatory care costs (ARR = 1.15; P < .01) and no differences in inpatient or total costs compared with the usual-care group. Conclusions. Initial increases in ambulatory care use from effective programs for underserved communities may mitigate savings from decreased acute care use. Longer-term outcomes should be followed to assess potential cost savings from improved health. Trial Registration: ClinicalTrials.gov identifier: NCT03924713. (Am J Public Health. 2022;112(5):766-775. https://doi.org/10.2105/AJPH.2021.306700).

FIGURE 1—

CONSORT Diagram of Randomized Medicaid Enrollees in the 3 Detroit, Michigan, Medicaid Health Plans Based on Eligibility and Active Criteria: February 2018‒June 2020 Note. CONSORT = Consolidated Standards of Reporting Trials; ED = emergency department; ITT = intention-to-treat. ^aEligibility was based on participant having either 3 or more ED days or at least 1 ambulatory care‒sensitive condition hospitalized day in the 14 months before randomization. ^bIndividuals not enrolled in plan for at least 1 month after randomization. ^cActive criteria were that beneficiary in community health worker (CHW) program was classified at final disposition by CHW as having been “partially” or “fully engaged” or reported providing a referral or taking any other action on behalf of the beneficiary.