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


At the time of our site visits, three of the four case study organizations (Aspen, Keystone East, and Kaiser Colorado) screened all new members through self-administered questionnaires provided as part of the new-member enrollment process. Keystone East used a 79-question form that focused on diagnoses, functional status, and self-perceived health and well-being. It included the SF-36, the Probability of Repeat Admission (PRA) instrument, a nutritional screen, and questions regarding health habits (for example, exercise and smoking) and receipt of preventive services (for example, mammography and prostate screening).14

At the time of the site visit, Kaiser Colorado had a formal screening program at only two clinics that are part of a pilot (out of 14 clinics in its delivery system).15 The two clinics serve a total of 11,000 seniors. Kaiser Colorado used a 47-question form that includes the PRA. In 1998, the Kaiser Colorado screening program was expanded to become planwide.

At Aspen, new-member screening was done by the Medicare + Choice Plan, Medica. However, Medica did not share any of the screening information it collected with Aspen, so this new-member screening did not influence care delivery directly.

At the time of our visit, screening at HMO Oregon differed according to whether a new member chose to have his or her care managed by a capitated medical group. HMO Oregon had undertaken risk screening on a pilot basis for those enrollees who did not elect to receive care from a capitated medical group. For those enrollees who elected to receive care from a capitated practice, the practice was responsible for any screening. Whether the process will be continued will depend on the results of the pilot. The questionnaire used by HMO Oregon included the PRA, along with additional questions relating to prescription drug use, smoking and alcohol consumption, and socioeconomic status.

Response rates for new-member screening varied among the organizations. The rates were approximately 66 percent for HMO Oregon, 70 percent for Keystone East, and 88 percent for Kaiser Colorado. All these response rates are very high for mail surveys, thanks to the intensive follow-up efforts the organizations made to obtain information from seniors who did not respond to the original mail questionnaire. The rates may also reflect the organizations’ efforts to make the screening part of the new-member enrollment process. Some seniors at Kaiser Colorado are given the survey when they enter an outpatient clinic, which may explain the particularly high response rate at this site.

The four organizations we studied were atypical in their use of long new-member questionnaires that solicit information for both screening and assessment. In the industry as a whole, brief screening instruments have been much more common (HMO Workgroup on Care Management 1996). The longer instruments provide more information for assessing the overall health and care needs of new members. In particular, the longer instruments provide a basis for assessing the risk for poor health outcomes, as well as the risk for hospitalization or high costs which can be predicted using fairly short instruments (HMO Workgroup on Care Management 2000; and Pacala et al. 1995). The longer instruments also appear to reflect the greater-than-average research orientation of the innovative MCOs included in our case study. The longer instruments used by the case study organizations appear not to have led to low response rates.

We found that the case study organizations generally made little use of the screening data. The major exception was that Keystone East used the data to help target new enrollees for their care management program. At the other extreme, Medica did not share any of the screening information with Aspen (which was responsible for delivering care to the Medica members who selected it as their primary care provider). At none of the sites did we find that the screening data were used for clinical purposes. Often the screening data were not sent to physicians or other staff involved in providing care. Keystone East made an attempt to share its screening data with its care managers, but the system was not effectively communicating the data at the time of our visit. Even when screening data were included in patients’ medical records, it appears that physicians paid it little attention. Instead, the physicians in our focus groups responded that they preferred to rely on their own examinations and discussions with patients. Care managers also seem to have conducted their own assessments of seniors referred to them. Thus, to the extent the new-member survey screening information was used, it was used by the MCOs to identify new members who should be encouraged to have a physician visit soon. The physicians and other providers would then be responsible for clinical assessments and any treatments.

Our case study MCOs used a variety of methods other than screening surveys to identify most of the high-risk seniors they referred to care management or disease management. Aspen and Kaiser Colorado identified high-risk seniors mostly through referrals by primary care physicians. HMO Oregon and Keystone East used a mixture of methods with the largest group of high-risk patients identified following an inpatient admission.

All organizations encourage physician referrals. Kaiser Colorado does so by meeting periodically with primary care physicians about when to make referrals, and it has distributed a one-page set of criteria for referrals. Kaiser’s general guidance to physicians is that, if in doubt, refer patients to care management. Aspen and Kaiser Colorado promote physician referrals by locating care management staff in the clinics so that they can interact with primary care physicians on a regular basis. Keystone East provides information in provider bulletins highlighting its care management program. Although it is not widely read, there is also a section on the topic in the provider manual. Finally, Keystone encourages self- referrals through its new-member “welcome call” program.

Focus-group physicians and care managers also reported that risk status often is identified in conjunction with treating specific, acute conditions. For example, one care manager described performing a presurgical screening for a patient facing a total hip replacement and determining that the patient had congestive heart failure as well. Another care manager told of identifying a woman with multiple chronic conditions, including a severe herniated disk, although the woman had initially contacted the care manager in search of help caring for her disabled husband. This woman had intentionally avoided seeking medical care because she was afraid she would be hospitalized and therefore be unable to care for her husband.

The combinations of methods used by these organizations tended to identify two to five percent of their elderly members as facing risks sufficiently high to warrant enrollment in care management. The two group-practice organizations, Aspen and Kaiser Colorado, identified two to three percent of their members as sufficiently high-risk to require care management. Keystone East used broader criteria for referral to care management, and correspondingly identified a higher fraction of its members as high-risk, approximately five percent.

The MCOs also tried to identify seniors who could benefit from disease management and other specialized programs. Again, they relied on a mixture of identification methods combined with a fairly simple assessment process that determined which programs might be appropriate. HMO Oregon analyzes its claims/encounter data to identify members with congestive heart failure. Kaiser Colorado had developed a registry for members with diabetes. All the MCOs also rely on physician referrals.

Each organization seems to have used an identification method that drew on its strengths. The two group-practice organizations relied on their clinic-based primary care physicians to refer high-risk seniors to co-located case managers. The close ties between physicians and organizations facilitated communication about the availability of care management and the types of seniors who should be referred. In contrast, Keystone East and HMO Oregon, which are IPA model organizations, had a less direct connection with their participating physicians, most of whom participated in several other managed care plans and accepted fee- for-service patients. Thus, it was more difficult for these organizations to get physicians to identify and refer high-risk patients. To overcome this difficulty, they drew on their administrative data systems and their new-member screening surveys to identify high-risk cases.

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