Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. 1. Care Management Processes


At all four case study organizations, care managers had a core set of duties. In general, their job was to coordinate access to medical care and community support services by working with patients who were at risk of hospitalization, or who had been hospitalized, to ensure timely access to services such as home health and both primary and specialty physician care.

The four case study organizations limited their care management efforts in various ways. Kaiser Colorado and HMO Oregon had programs that generally limited intensive care management services to a 4- to 6-week period. Keystone East limited most care management contact to the telephone. In addition, the relatively high caseloads assigned to care managers at Keystone East had the effect of limiting the average amount of attention provided to high-risk seniors. In general, the four organizations tried to focus their care management efforts on assessment, care planning, and referral to support-service providers in the community. They placed less emphasis on long-term patient education, ongoing advocacy, and long-term monitoring. While they recognize the potential value of long term care management services, they generally referred seniors to community organizations to obtain that care. In addition, they tended to rely on primary care physicians to identify new problems or on the seniors themselves to recontact the care management program.

These limitations appear to reflect an effort to spread available resources in a way that helps the most people with needs. Care management is not a covered Medicare service, and thus the MCOs are not directly compensated for providing it. Based on our discussions with staff at the four organizations, it seems that the organizations have designed their care management efforts to focus on resolving medical or social crises with an emphasis on short-term efforts that would stabilize a person rather than on long-term monitoring and advocacy. This approach let the MCOs use a relatively small team of care managers to address problems for many seniors. The approach appears to be based on a sense that once a person’s situation has been stabilized, it is better to spend the available resources stabilizing another person than to continue to deliver long-term monitoring services to the first person.

Financial constraints were especially clear at Aspen, where staff felt that Medica’s recent decision to pay Aspen on a fee-for-service basis rather than through capitation would not provide enough resources to operate the program without the additional funding Medica provided specifically for care management.

To some extent it appears that the organizations felt that the limited duration of the care management was consistent with the ongoing responsibility of the primary care physicians to monitor patients. The high-risk seniors targeted by the care management programs tend to have frequent physician visits. Thus, the physicians are in a position to monitor their patients’ progress and to re-refer patients to care management if necessary.

Care managers also coordinated access to community-based social services, although the MCOs rarely paid for these services. Instead, the organizations ensured that the care managers were familiar with local resources, and the care managers either made referrals or set up arrangements with local programs. These programs included congregate or home- delivered meals, opportunities to socialize at senior centers, exercise programs geared to elderly or disabled people, transportation services, Medicaid home and community services, and opportunities to volunteer or be contacted by volunteers. These services address problems such as social isolation, failure to thrive, depression, and limitations on basic activities of life in the expectation of reducing the need for inpatient or other high-cost services.

All four case study MCOs dealt with local Area Agencies on Aging, which are funded under the federal Older Americans Act and either are based in local government agencies or operate as private nonprofits. Keystone East, for example, has a close relationship with the Philadelphia Corporation on Aging (PCA), which provides in-home services, has support groups, and maintains a friendly visiting program for the homebound. These services are paid for by the enrollee or supported by the community rather than the health plan. One problem in accessing PCA and other social service agencies is that many of them have waiting lists for services.

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