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High-Risk Veterans with Access to Primary Care Intensive Management Receive Increased Outpatient Care without Increased Cost

Patients at high risk for poor outcomes often have multiple chronic conditions, financial constraints, and behavioral problems, as well as poor functioning and low health literacy skills leading to potential difficulty following providers' advice. Intensive Management (IM) models aim to proactively reduce complex patients' deteriorations in health and resultant high-cost hospitalizations through interdisciplinary teams, care coordination, and support for care transitions. This study evaluated the impact of outpatient primary care IM programs on health care utilization and cost at five VA medical centers. Veterans at high risk of hospitalization (n=2210) were randomly assigned to patient-centered medical home usual care or IM. Costs and utilization were examined 12 months before and after randomization.


  • Veterans receiving IM care had higher utilization of outpatient care without an increase in total costs (including costs of the IM program) or differences in mortality over a 12-month period.
  • Veterans in IM care had greater use of outpatient services such as mental health/substance abuse care, home care, and palliative/hospice care both in person and by telephone. Increased outpatient costs were attributed to higher use of these services.
  • Veterans in IM care had a statistically significant reduction in nursing home days and non-significant trends toward lower mean inpatient costs, number of inpatient stays, and number of hospital days.
  • IM programs appeared to improve access to necessary outpatient services and improve engagement in care.

Intensive management programs were associated with cost-shifting from inpatient to outpatient care. Increased referrals to and use of patient-centered services within and outside of primary care suggest that IM teams' comprehensive assessments are directing Veterans to existing services that are likely to help meet these complex patients' needs at no additional overall cost.


  • The five study sites may have had more organizational resources and experience with primary care innovations, so results may not be generalizable to all VA sites.
  • Sites took up to several months to contact eligible patients and assess them for services, so 12 months may be too short a period to observe meaningful impacts on inpatient care.
  • Researchers did not analyze prescription drug data or non-VA utilization that was not sponsored by VA, so it is unclear what impacts IM may have on such utilization.

Dr. Yoon is part of HSR&D's Health Economics Resource Center (HERC), VA Palo Alto Health Care System. Dr. Chang is part of HSR&D's Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA.

PubMed Logo Yoon J, Chang E, Rubenstein L, et al. Impact of Primary Care Intensive Management on High-Risk Veterans’ Costs and Utilization: A Randomized Quality Improvement Trial. Annals of Internal Medicine. June 19, 2018;168(12):846-54.

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