Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. 3. Implications for This Study of High-Risk Seniors in Medicare Managed Care


An implication of our conceptual framework is that seniors outcomes are shaped by a wide array of factors, only some of which are under the control of their managed care plan. These factors may vary from community to community and from person to person. The effects of any systematic effort an MCO makes to affect the delivery of care can be masked by the variation among high-risk seniors in the extent to which they can draw, or wish to draw, on family, friends, social service providers, and themselves to meet their needs. The effects of MCO efforts can also be masked by differences in the local availability of senior-related community services (such as home-delivered meals and financial aid for purchasing needed medications) that influence outcomes, particularly the extent of unmet needs for help with ADLs.

This difficulty in identifying the specific effect of an MCO means that our case study of only four MCOs will not be able to come to definitive conclusions about links between MCO structure and beneficiary outcomes. Nevertheless, we feel that it is possible to identify some suggestive patterns in the information we collected about MCO structure and in the experiences high-risk seniors report in our surveys. The combination of detailed operational information gathered from site visits to all four MCOs and consumer survey information gathered from beneficiaries in three of those MCOs gives us a strong base for examining ways in which MCO features may affect outcomes. In looking among these MCOs, we have seen that different MCO approaches are associated with differences in beneficiary perceptions about the MCO services. These patterns suggest challenges that all MCOs will face in serving high-risk seniors and offer some suggestions about useful ways to address those challenges.

The conceptual framework also highlights the potential importance of care management for coordinating the organizationally complex mix of services and providers. The set of services included in “care” can be very large for high-risk seniors. As a group, they are likely to have more providers, paid and unpaid, than other beneficiaries. They are likely to need medications and social support services that are not covered by Medicare and are delivered by providers who are not contractually linked to the MCOs. They and their families will often have to play a major role in monitoring the dynamic nature of their chronic conditions and complying with multi-part treatment regimens. Interest in making this fragmented system work effectively and efficiently leads naturally to interest in care management. Thus, it was not surprising that care management plays a key role in how the case study MCOs arrange care for high-risk seniors.

While interest in care management is high, we expect that MCOs will be cautious in their use of this service. Care management is not a covered Medicare benefit, and there is little clear evidence that it can generate net savings. Therefore, MCOs would be expected to undertake fairly limited care management programs until they develop a better sense of the ways in which such programs are affecting their net revenues and the health outcomes of their beneficiaries. In addition, we would expect that MCOs would deliver care management that focused on assessment and coordination of medical care. We would expect them to refer high-risk seniors to local social service providers for services that lie outside the Medicare benefit package (such as home-delivered meals or respite care for unpaid caregivers).

We also expect that MCOs organized as group or staff models will have more control over their providers than will Individual Provider Associations (IPAs) or network MCOs. The close relationship between MCOs and providers in group models gives these MCOs an internal source of ideas for making care more efficient and cost-effective, as well as a more direct ability to influence how care is delivered. In addition, group or staff MCOs would be expected to attract physicians and providers who are more comfortable with prepaid medicine. In contrast, network or IPA models tend to include providers that contract with several other MCOs as well as treat patients who have fee-for-service coverage (Collins et al. 1997). Thus, providers in these networks face multiple sets of financial incentives and, in some cases, multiple suggested care protocols and monitoring procedures. Any one IPA or network plan will therefore have only a limited ability to shape the care delivered by providers.

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