Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. 2. Many Seniors Were Unaware That They Had Been Enrolled in Care Management


Many people in our care management sample seemed to be unaware that they were in care management. Even though this sample of seniors was selected from MCO-provided lists of members in care management, only 21 percent knew that they had a care manager from their MCO (Table V.14). This fraction varied from 19 percent at Keystone East to about 40 percent at Aspen and Kaiser.

TABLE V.14. Percentage of Sample Members in Care Management Who Knew They Had a Care Manager
  Measure of Whether Sample Members  
Knew They Had a Care Manager
  All MCOs   MCO
  Aspen   Kaiser
Reported Having a Care Manager from Their Plan 21.4 40.1 36.3 19.3
Reported Having a Care Manager from Outside Their Plan 9.7 11.6 7.3 9.8
Reported Any Care Manager 28.1 45.5 40.1 26.3
SOURCE: Telephone survey of 740 seniors selected from MCO-provided lists of members in care management. The interviews were conducted between March and December 1999 by MPR.
NOTE: Values are percentages, with standard errors in parentheses.

Because there may have been confusion about whether the care manager worked for the MCO, we also asked if sample members had a care manager from outside their plan. This was particularly important for sample members from Aspen, where the care managers were part of the medical group, not the Medica plan. An additional 10 percent of the sample members reported such a care manager. When responses to both questions are combined, they indicate that only 28 percent of the seniors in the care management sample knew that they had a care manager.

The fact that many seniors were unaware that they were in care management reflects, in part, the timing of the survey. In particular, the care management samples for Kaiser Colorado and Keystone East were drawn from a list of seniors who had been in care management at some time during the first three quarters of 1998. The Aspen program had been initiated more recently, so the sample included seniors who had received care management services from November 1998 through February 1999. The interviews were conducted from March to December of the following year. Because of this timing, many of the seniors may have received the bulk of their care management services well before they were interviewed. With the amount of care these seniors receive, it is not surprising that they did not remember the earlier care management services.

The organizationally complex care may also make it difficult for care managers to stand out from all the other providers who work with high-risk seniors. These seniors receive care from their primary care physician, specialists, therapists, nurses, community-agency staff, and the office staffs of these providers. Each care manager at the case-study MCOs was a nurse and may have appeared to the seniors as just another nurse who was working with their physician. This suggests that it can be hard to make care management salient among high- risk seniors unless the care managers have the time to build a personal relationship with their patients. In our focus groups with seniors in care management, many of the seniors remembered getting help from a nurse and often associated that nurse with the MCO. They did not, however, think of that nurse as someone who could provide ongoing help or someone to call if they had a problem with care coordination or access. However, this does not mean that care management was never salient to the seniors. Many of the seniors in our care management focus group at Kaiser Colorado spoke in very positive terms about their care manager, whom they knew by name and cited as the answer to most of the access or coordination problems that might arise.

The differences in the MCOs’ care management programs probably accounts for some of the differences among MCOs in the fraction of seniors who knew they were in care management. After our site visits and focus groups, we felt that the clinic-based care management programs operated by Aspen and Kaiser Colorado were more likely to promote a close relationship between care manager and senior. This is borne out by the data: seniors in our care management sample were about twice as likely to know they were in care management at these two MCOs as they were at Keystone East.

Also, the lower recognition rate at Keystone East may reflect the higher caseloads at that site (Table V.15). In addition, Keystone East care managers only contacted seniors by telephone; different nurses from a home care agency made any home visits. Thus, seniors at this MCO would have had less direct contact with their care manager and, correspondingly, would be expected to have less of a sense of being in active care management.

TABLE V.15. Care Management Caseloads at the Case-Study MCOs
    Aspen Medical  
  Kaiser Health Plan  
of Colorado
  Keystone Health  
Approximated Care Manager Caseload   70 50 130
SOURCE: Information collected during the site visits to the three MCOs

Finally, there are a few general reasons why care managers may not be salient to seniors in care management. These include:

  • At group models, the care managers and primary care physicians are more likely to think of each other as a team. This may promote the perception among seniors that the nurse care manager is only an extension of the primary care physician rather than someone who can provide direct assistance on a wide array of issues

  • In contrast, at IPAs the MCO may have to avoid creating an impression that they are interfering with the care provided by network physicians. Therefore, the MCO’s care managers may actively seek to remain in the background.

  • In some IPAs the primary care physicians may be contractually required to managed care for patients. If the MCO feels that those physicians are not doing as well as they could, they may not want to embarrass them by having highly visible care managers working with patients.

Nevertheless, some care management programs can produce salience, even with a time- limited care management intervention. Some programs have achieved nearly 100 percent familiarity with care managers’ names among the seniors served by the program, even when the average length of stay was under 75 days (Aliotta 2001). Those programs feel that a key factor in promoting salience is the extent to which the program makes it a priority to have care managers develop a close relationship with the seniors.

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