Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. 2. Diverse Characteristics of High-Risk Seniors


The general characteristics and variability of high-risk seniors has been well documented (Levkoff et al. 1988; Pope and Taslov 1991; Fox and Fama 1996; and Stone et al. 1987). These characteristics are also seen in our sample of high-risk seniors, particularly the high levels of chronic illness and functional limitation summarized in the prior chapter (Table II.5). A sizable minority are limited in their ability to engage in three or more ADLs, with a few limited in all five.12 Most high-risk seniors in our sample have 2 or more chronic conditions, and some reported more than 10. In addition, there are several important types of variation that mirror the variation in the overall Medicare population. In particular, variation in education, income, and living arrangements (Table II.4 and Table II.5) have important implications for access to care.

From the perspective of MCOs that want to serve high-risk seniors, it is particularly important to note the variation with respect to the mix of conditions and functional limitations. Individuals with multiple chronic conditions or impairments need a more comprehensive care management program rather than focused disease management programs. The care management programs must be able to address many different combinations of chronic illnesses and limitations with respect to ADLs and IADLs. For example, Table III.1 shows that seven percent of our sample of high-risk seniors who live in the community report three or more chronic conditions and limitations in three or more ADLs (questions about limitations in ADLs were not asked of seniors living in nursing homes). Further analysis of this particularly high-risk group indicates that more than half these seniors have less than a high-school education, and almost half report annual incomes of less than $10,000 (Table III.2, last column).

TABLE III.1. Distribution of Chronic Conditions and Functional Limitations in Our Sample of High-Risk Seniors
Number of
  Number of Chronic Conditionsa     Total   Number of
0 1-2   3-12  
0 9 34 30 73 962
1-2 1 6 12 18 273
3-5 0 2 7 9 164
Total Sample 10 42 49 100 1,399
Number of Observations     107     515   777 1,399  
SOURCE: Sample of 1,399 community residents taken from telephone survey of 1,657 high- risk seniors from three managed care organizations, conducted between March and December 1999 by MPR.
NOTE: Values are percentages and are weighted to represent the population and correct for nonresponse.
  1. People were asked whether they had been diagnosed with any of the following chronic conditions: arteriosclerosis, hypertension, heart attack, other heart disease, previous stroke, depression, cancer, diabetes, arthritis, asthma, previous hip fracture, and Alzheimer’s or other dementia. Totals for this variable will not match those in Table II.4, because this sample is restricted to the 83 percent of our sample who lived in the community.
  2. Limitations in activities of daily living involve the need for help or supervision with the following: bathing, eating, dressing, transferring, and toileting.

While the exact figures will differ for other samples of high-risk seniors, the need to accommodate people with diverse mixes of conditions, functional limitations, education, and income will characterize all groups of high-risk seniors.

High-risk seniors generally must take an active role in their own health care to maximize their health and functional independence. The variation in their attitudes and capacities, which could affect their actions in this regard, should thus be taken into account when customizing their treatment protocols. For example, in our sample 29 percent of seniors with three or more chronic conditions and one or two ADL limitations (Table III.3, second column) reported that they would do just about anything to avoid seeing a doctor. If this means that they ignore the early signs of an illness, for example, then this attitude could be an obstacle to effective care. Attitudes such as this introduce yet another variable that MCOs encounter in the process of caring for high-risk seniors.

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