Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. 1. Site Visits and Focus Groups


We used site visits and focus groups to collect information about the structures and processes the MCOs used to care for high-risk seniors. Most of this information was collected during three-day site visits conducted by three of the authors of this report (Drs. Fox, Retchin, and Thornton). Prior to each visit, we reviewed information on the health plan, including benefit packages, market area, Medicare enrollment growth, and any documents the organization could provide that described their special programs for high-risk seniors. During each visit, we spoke with the director of Medicare programs, the medical director, and the director of care management. We also spoke with the care management supervisors and staff from any special programs for elderly Medicare beneficiaries with chronic illnesses or disabilities. Site visits included four separate focus groups with physicians, care managers, seniors enrolled in the organization’s care management program, and seniors with a recent hip fracture or stroke. We also spoke with managers at skilled nursing facilities and home health agencies that served large numbers of the organization’s patients. Finally, we spoke with the director of the local Area Agency on Aging in order to get an overview of the services available locally. We held follow-up telephone interviews with several of these people to obtain supplementary information. Overall, we talked to more than 150 people in conducting the case studies.

TABLE II.2. Characteristics of Area Health Care Markets and Practice Patterns
St. Pauld
Population, 1996e 2,125,212 3,723,835 1,375,518 2,509,572 265,284,000
Medicare Beneficiaries, 1996f 236,005 598,730 175,894 286,722 37,164,000
Percentage of Population Age 65 and over, 1996f 9.2% 14.5% 11.9% 9.7% 12.8%
Managed Care
Overall HMO Penetration Rate, 1996g,h 36.0% 37.0% 48.7% 44.2% 20.3%
Medicare Risk Plan Penetration Rate, 1997f 40.0% 29.4% 48.7% 32.9% 12.9%
Medicare Payment Level, 1998f $408-$514 $522-$718 $383-$412 $367-$431 $472i
Physicians and Hospitals
Family and General Practitioners per 100,000, 1996g,h 25 18 17 36 22
Specialists per 100,000, 1996g,h 168 191 148 133 136
Hospital Beds per 1,000, 1995h,i 2.3 4.2 2.1 2.4 3.3
Admissions per 1,000, 1995h,i 91 163 94 105 117
Inpatient Days per 1,000, 1995h,i 470 1,127 404 572 753
Average Length of Stay, 1995h,i 5.1 6.9 4.3 5.4 6.5
  1. The Denver area refers to the counties in the Denver and the Boulder-Longmont Primary Metropolitan Statistical Areas: Adams, Arapahoe, Boulder, Denver, Douglas, and Jefferson.
  2. Unless otherwise noted, the Philadelphia area refers to the five counties in Keystone East>s service area: Bucks, Chester, Delaware, Montgomery, and Philadelphia counties.
  3. Unless otherwise noted, the Portland area refers to the four counties in HMO Oregon>s service area: Clackamas, Columbia, Multnomah, and Washington counties.
  4. Unless otherwise noted, the Minneapolis-St. Paul area refers to Anoka, Dakota, Hennepin, Ramsey, Scott, Washington, and Wright counties.
  5. U.S. Census Bureau 1997.
  6. Health Care Financing Administration 1997.
  7. Interstudy 1997.
  8. For some market areas, the statistic is for the plan’s approximate service area; data were not always available for the exact area.
  9. American Hospital Association 1996/1997. U.S. average payment level.

In preparing to analyze the site-visit information, we first developed reports on each of our site visits. Those reports were reviewed by staff at the participating organizations, to ensure that we reported facts about the organization accurately. Similarly, this report has been reviewed by key staff at the four organizations as well as by our Technical Advisory Panel. The authors, of course, remain responsible for any remaining errors and for the interpretation of the information provided.

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