Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. B. Care Management Was a Major Innovation for Treating High-Risk Senior in All Case-Study Organizations


All four MCOs in our study developed some form of care management among their various innovations. For high-risk seniors, care management appears to be a critical component for coordinating organizationally complex care that involves multiple providers, services, and facilities. For MCOs, care management provides a way to pursue two objectives simultaneously: improving care to high-risk seniors and reducing the need for high-cost services.

The four organizations used different methods to channel between two and five percent of their Medicare seniors into care management. In fact, our discussions with physicians and care managers at all four organizations emphasized that no single method will identify all high-risk seniors, so organizations must use multiple methods, including both physician referral and review of inpatient admissions.

The group model organizations relied predominantly on primary care physicians to identify high-risk seniors. This reflects the inherently close relationship with these organizations and the primary care physicians. It also reflects their decision to locate care management staff in the clinics. This co-location promoted frequent communication among care managers and primary care physicians, which in turn helped produce a shared sense of mission for care management. Care managers at these organizations saw their ongoing interactions with physicians as essential to getting referrals to care management. In particular, they saw it as a way of persuading physicians to start making referrals. Once the care managers had achieved success with a few of a physician’s patients, the physician was much more likely to refer additional cases and to participate more actively in the care management process.

In contrast, the IPA model organizations used inpatient admissions as the predominant method for identifying enrollees at high risk for intensive resource utilization. This approach reflects the challenges faced by IPA model organizations with large, loosely integrated physician networks, networks that were much larger than those used by the group model organizations. Thus, it was infeasible to place care managers in office practices or clinics, where there were enough high-risk seniors to warrant such an investment.

While all four case study organizations used surveys to screen their new members, none of them appear to have used that information for clinical purposes. At the extreme, one plan did not share information collected in new-member screening surveys with the primary care providers. In other cases, the screening information was entered into patients’ medical records or otherwise made available to physicians or care managers. However, in these cases, the providers preferred to make their own assessments and did not appear to use the screening data.

Therefore, the value of the new-member screening surveys appears to lie in their ability to help MCOs target people who should be encouraged to see their primary care physician as soon as possible. One case study organization also used them as part of its effort to identify members who would benefit from special programs such as care management or disease management. At the same time, there seemed to be little interest among our case study MCOs in using screening surveys to assess existing members. MCO staff indicated such surveys yield a high rate of false positives and are not a cost-effective way of identifying high-risk members. Instead, the MCOs preferred to rely on physician-referral or on using their existing data systems. There is evidence that screening based on claims/encounter data is more efficient than that based on surveys (Coleman et al. 1998).

Another feature that distinguished care management at the group and IPA model organizations was the mode of contact between care managers and the seniors. Both Kaiser Colorado and Aspen located care managers in their clinics, where they could have face-to- face contact with patients. This approach appears to have given patients a much greater awareness of the care management programs than in the programs where care managers used only the telephone to communicate with patients.

The decision to have face-to-face contact between care managers and patients also seemed to promote better understanding among seniors about the full role of care management, although the evidence on this point comes primarily from the focus groups. All the care management programs seemed to coordinate care among the various providers who might be treating a patient. The programs with face-to-face contact, however, seemed to foster a stronger sense among the seniors that care management was an ongoing source of information and advocacy. In particular, care-managed seniors at all the organizations often were aware of receiving nursing services and assistance, but generally they did not see care management as an ongoing source of help. Only at the Kaiser Colorado focus group did we hear seniors describe their care managers as people to whom they would turn if they needed information or help arranging for care. While there could be several reasons for this, it seems likely that the distinguishing factors at Kaiser Colorado were its combination of face- to-face contact with seniors and its assignment of seniors to a single care manager rather than to a care management team. The survey data tend to support this conclusion. The care management samples at Aspen and Kaiser Colorado were more likely than Keystone East’s to report being in care management.

The salience of care management at Kaiser Colorado and Aspen was also fostered by their smaller caseloads: care managers at Aspen and Kaiser Colorado tended to be responsible for 50 to 70 patients at a time, while managers are Keystone East generally had caseloads of 130. Discussions in our focus groups suggest that the smaller caseloads resulted in greater time spent on each case by the managers, and likely also meant higher costs per case and a shorter duration of active care management.

It is noteworthy that the structure of the IPA model type did not necessarily inhibit experimentation. In addition to care management and disease management programs, we also noted other IPA innovations, such as the instance where a capitated provider group in HMO Oregon>s network has initiated an experimental program using resource specialists. In that program, staff without nursing backgrounds provide care management for people with functional deficits of a milder nature than most health plans would regard as warranting care management.

One innovation we saw at all case study organizations was care manager referrals to community services, including home-delivered meals, senior centers, transportation assistance programs, personal assistance, subsidized housing, and custodial-level nursing homes. In the fee-for-service sector, community agencies, such as the local Area Agency on Aging, would provide this information, as well as referral assistance, to those seniors who contacted the agency. The case study organizations used their organizational infrastructure to channel high-risk beneficiaries to community services that they may not otherwise have sought. The MCOs do not pay for these services, which are excluded from their contracts with Medicare. However, their efforts can improve access to these services. The care managers’ knowledge of the various community programs can help ensure that seniors get access more effectively than if they tried to obtain those services on their own. In the best cases, the care managers not only provided referrals, but also monitored seniors to determine that services were provided.

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