Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. B. Care Management


Care management lies at the heart of an organization’s efforts to promote good care for high-risk seniors. In general, it is a collaborative process that assesses needs, develops care plans, and then implements and monitors those plans in order to promote high-quality, cost-effective care (Case Management Association of America 1995). For high-risk seniors, care management can promote communication and coordination between the numerous providers who work with a specific person. It can ensure delivery of tertiary preventive care--care intended to help people who have already developed chronic conditions, serious impairments, or frailty to maintain or recover their health and functioning. Such preventive care can help mitigate the consequences of chronic disease and frailty, as well as help control costs by reducing the likelihood that these seniors will require expensive treatments.

Care management is distinct from utilization review programs. Aliotta (1996) points out that care management and utilization management have different focuses. Utilization management systems seek to control costs, ensure medical necessity, and help plans identify trends in care delivery. Utilization management tends to be reactive, focusing on acute care episodes, with emphasis on reducing the length of hospital stays and planning discharges effectively. Utilization management also focuses on providing low-intensity services to a large number of people. In contrast, care management takes a more proactive approach in shaping care for individuals. Care management focuses on assessing risk, intervening early, and promoting consistency and continuity among the wide array of services a person may need. In addition, care management tends to provide intensive services to specific groups of plan members, most often identified through rigorous targeting efforts.

Attempts to promote care management among MCOs are hindered by the lack of clear evidence that it is a cost-effective means for improving care, or even for promoting an MCO’s image in the community. A recent study of best practices in care coordination reviewed evidence for 157 different programs and found some evidence that care management can work, in the sense that it can reduce hospitalization rates for carefully targeted groups (Chen et al. 2000). That study found very little information about the specific program characteristics that make a care management program work and even less on what it takes to generate cost savings. What little evidence they found suggests that successful care management programs tend to follow a general approach that starts with an assessment of each person in order to develop a care plan, followed by structured efforts to implement the plan, monitor the patient and care plan, and adjust the care plan as necessary (Chen et al. 2000). Nonetheless, these programs are expensive and thus require careful targeting of high-risk enrollees or those with specific chronic illnesses, to ensure cost-effectiveness (Mukamel et al. 1997).

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