Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. C. MCOs Fielded a Wide Mix of Initiatives in Addition to Care Management


All four MCOs went beyond the basic Medicare benefit package. They all implemented disease management programs, although they differed with respect to the disease they targeted. The two most common disease management programs were for congestive heart failure and diabetes. Although some aspects of the organizations’ programs were similar, the procedures and pathways used varied in different ways. All the programs were developed by the MCO rather than purchased from external vendors. The programs also emphasized the importance of local physician opinion leaders. Of the disease management programs we reviewed, Kaiser Colorado’s were the most extensive. Among the more innovative and pragmatic disease management programs, Kaiser Colorado had developed an anticoagulation service that directly managed the constantly fluctuating anticoagulant dosage requirements of patients taking these medications. This program, with a caseload of about 3,700 patients, utilized seven pharmacy staff, who carried laptops connected to their laboratory information system. Because of Kaiser Colorado’s group model structure, pharmacists in the program found it easy to communicate consistently with primary care physicians regarding medication changes. Kaiser Colorado had also developed a diabetes registry through their laboratory information system to identify diabetics with special needs and to ensure coordinated care for this group of enrollees.

Keystone East also developed a noteworthy program for treating patients who needed joint replacements. To help ensure that the program would be accepted throughout its physician network, Keystone East organized a team of respected specialists from its market area to develop its program. The program includes presurgery home visits by a nurse to assess patients’ readiness for surgery and to prepare patients and their homes for their subsequent return. The program also includes home visits after surgery to help seniors with their recovery.

It was evident that home health visits were used extensively to conduct home evaluations and interventions beyond those covered by the basic Medicare benefit package. Beneficiaries and their families appeared to be pleased with these services. Even physicians who were not fully familiar with the care management program extolled the virtues of the home evaluations, particularly as a method for evaluating home safety and functional status.

The organization of services for institutionalized enrollees also was a noteworthy innovation in the delivery of care for high-risk seniors. For example, three of the four HMOs admitted patients directly to skilled nursing facilities, waiving traditional Medicare guidelines requiring a three-day hospital stay. Moreover, all four MCOs used their contracting process as an opportunity to review the quality of care at different nursing homes, and to impose supplementary standards for participation beyond those required by Medicare. These included having accreditation for delivering subacute care, the ability to administer antibiotics intravenously, and the capacity to perform heart monitoring. They also included operational criteria such as being able to admit patients 24 hours a day (including weekends), offering rehabilitation services at least six days a week, having clinical functions provided by permanent staff rather than outsourced, and being staffed primarily with registered nurses rather than licensed practical nurses.

Furthermore, the two group model organizations limited their network to only a few facilities. The small network of skilled nursing facilities made it easier to secure dedicated beds to facilitate transitions from inpatient care, and reduced the burden on discharge planners and care managers for this purpose. Moreover, at the group model organizations, the physicians who cared for patients at skilled nursing facilities were organized into a special subcomponent of the group practice. This facilitated familiarity between the nursing home staffs and physicians and promoted more availability of providers for families, residents, and staff at the facilities. Again, the group model organizations offered the opportunity for this type of physician specialization to foster facility-specific skills and other efficiencies similar to those gained from hospitalist approaches. Although the group model organizations appeared to take particular advantage of their narrower physician network for organizing special programs to help manage care for people in nursing homes, one of the IPA model organizations, Keystone East, also fostered long-term care services by providers through special payment arrangements. This latter effort encouraged physicians with special interests in the nursing home population by giving them increases in their monthly capitation payments.

The two group model organizations used versions of the hospitalist model for inpatient care. These organizations took advantage of the higher degree of organization with their group practices and allowed their physicians to structure the inpatient care in a more concentrated manner. Although this allowed for greater efficiency in delivering inpatient, acute service, it also led to issues regarding continuity of care. For example, some care managers lamented that this often led to difficulties in communicating issues in the transition between outpatient and inpatient settings. The seniors in our focus groups also expressed concern that this type of approach might reduce the continuity of their care.

All organizations took advantage of the flexibility provided by capitation to offer some off- policy benefits. This flexibility, while not routinely exploited, was utilized in special situations. On occasion, physicians were particularly enthusiastic about the opportunities for using this flexibility for specific patients, and some deplored the limitations of the conventional Medicare fee-for-service guidelines. The most commonly provided off-policy benefits were home visits to evaluate seniors who did not meet the Medicare fee-for-service criteria for home health care. Other off-policy benefits included the provision of durable medical equipment beyond Medicare guidelines or home modifications and help with nutritional issues. Use of these other benefits was generally quite limited, and their use was controlled by the organizations.

At the time of our site visit, Kaiser Colorado was completing its electronic medical record system. This system appears to offer substantial opportunities for improving the delivery of care for high-risk seniors. Since Kaiser Colorado already has a centralized information system, albeit not a paperless medical record, they have had ample experience using this common data source for reducing duplicative tests and medications that can lead to untoward iatrogenic complications. The centralized record also facilitates communication among the many providers who deliver care for high-risk seniors. Kaiser Colorado’s electronic medical record illustrates another advantage of the group model HMO. It is hard to imagine how an IPA would finance and implement such a system, because the IPA typically would cover only a minority of the patients seen by any of the physicians in their network.

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