Care management was a key element in the efforts all four MCOs made to address the needs of high-risk seniors. Yet the care management programs they implemented were generally more limited than those for which Chen et al. (2000) found some evidence of effectiveness. The case-study organizations developed care management that was typically time limited and focused on assessment, coordination of medical care, and referral to community organizations for social support services. They placed less emphasis on ongoing activities such as monitoring and adjusting the initial care plan. Their choices appear to reflect a view of care management as supplementing the efforts of primary care physicians. In particular, the role of long-term monitoring and re-referral to care management was usually left to the primary care physicians at all four organizations. Their choices also reflect the fact that at the time of our site visits care management is not part of the Medicare benefit package and therefore not something they are directly paid to provide or required to provide. Finally, their choices reflect the general lack of empirical evidence about what it takes for a care management program to generate net savings.
The limited nature of the care management efforts fielded by the case study organizations was often reflected in the perceptions of the directors of the local Area Agency on Aging. In most cases, the directors knew little about the specific care management programs fielded by the MCOs. Instead, the agency directors were unhappy with the general level of care management that managed care plans provided. In particular, they felt that the plans often left a lot of the work for the agency. This perception was correct in the sense that the MCOs focused on coordinating Medicare-covered medical services and referred members to the Area Agencies and other community organizations for help with many support services, including transportation assistance and respite care for caregivers. In essence, the MCOs took the initiative to identify high-risk seniors who would benefit from social support services, to refer those seniors to appropriate community agencies, and to follow-up to ensure that the referrals resulted in services. This effort appears to have helped the seniors, but may have also increased the overall demand for services from the community organizations. Such increases in demand could be expected to be met with lukewarm enthusiasm from the Area Agencies who were often struggling to keep up with requests for assistance.
The four case study organizations made different decisions about caseloads and the extent to which their care managers could provide individual attention. Care managers at Keystone East had high caseloads and contacted patients only by telephone, which avoided the need for care manager travel. Keystone East and Aspen also pursued efficiency by using specialized staff. At Keystone East, in-home assessments were conducted by home care nurses. At Aspen, a patient might see one care manager in the hospital, someone else while receiving home care, and a third person when they were home after the home care ended. The efforts of the specialized staff were then coordinated by an Integrated Services Coordinator. HMO Oregon concentrated its care management efforts on the seniors who had not selected a capitated practice for their primary care. It also relied on care management efforts developed by some of the health systems with which it contracted.
A common element in all the care management programs was that many seniors enrolled in care management did not seem to be aware of their enrollment. We saw this in our focus group discussions with seniors who the organizations had indicated were in care management (we saw the same result in our survey data which are discussed in the next chapter). The level of awareness varied among the four organizations, with care-managed seniors at Kaiser Colorado having the clearest connection with their care managers. Not only did most know the name of their care manager, but they seemed to view care management as a means for helping them get the care they required, rather than a series of unconnected events in the care delivery process. Care-managed seniors who participated in focus groups at the other organizations tended to remember receiving care and monitoring telephone calls, but saw these services more as isolated events than as part of a care management process. This is not to say that care for seniors at the other sites went uncoordinated, merely that the care coordination and information provision roles of care managers went largely unnoticed by seniors at these sites.
The differences in seniors’ perceptions seem to be related to different choices the MCOs have made about the structure of care management. Keystone East’s use of telephonic care management and high caseloads may have made it hard for patients to understand care management or to distinguish it from many other MCO or provider interactions. The use of specialized care management staff at Aspen may also have inhibited patients’ awareness of care management. In particular, the coordination provided by Aspen’s Integrated Services Department may not have been visible to the seniors. This pursuit of efficiency at both Keystone East and Aspen seems to have reduced the sense that seniors had of care management as a source of ongoing advocacy, information, and care coordination. In contrast, care-managed seniors in our focus group at Kaiser Colorado reported more direct contact with between care managers. Seniors understood care management better as a result of this interaction and the fact that each senior dealt with only one care manager rather than a team. However, even at Kaiser Colorado, there seemed to be variation among seniors who were managed by different care managers. This implies that the personality and individual styles of care managers can affect seniors’ perceptions.
Primary care physicians seemed to have the best understanding of care management at Kaiser Colorado and Aspen. At these sites, physicians who participated in our focus groups tended to know about the ways in which care management could help their patients and how to refer patients to it. At Keystone East, the physicians who participated in our focus group were generally unaware of the plan’s care management program. Physicians serving seniors at HMO Oregon showed a pattern that is consistent with this plan’s use of both the group and IPA models. In particular, physicians in capitated practices at HMO Oregon knew about the care management of their own practice, while individual physicians did not appear to know much about the care management provided by HMO Oregon. It seems likely that the differences in perceptions are due to clinic-based provision of primary care at Kaiser Colorado, Aspen, and in some practices in HMO Oregon. The clinics enabled these organizations to place care managers in close working proximity to the primary care physicians. They thereby helped to identify high-risk seniors and to manage care for such seniors. This approach was more efficient at the IPA model health plans because there are so many independent practices. Keystone East tried to address this issue by assigning care managers to specific sets of physicians, but the lack of direct contact with physicians seems to have reduced the effectiveness of this approach.