Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. CHAPTER II. STUDY POPULATIONS AND METHODS


The goal of our case studies has been to understand the perspective and experiences of elderly Medicare beneficiaries who have enrolled in innovative managed care organizations (MCOs) and who are known to those organizations as having high risks for hospitalization and adverse health outcomes. We focused on this group to get an idea of the ways in which managed care could help high-risk seniors. High-risk seniors who had not been identified by their plans clearly require attention, but studying those people would not allow us to observe any proactive services. In addition, high-risk groups of seniors provide an important sentinel group for studying the performance of managed care organizations (Patterson et al. 1998).

We began our case studies by selecting four innovative MCOs: three managed care plans with capitated Medicare + Choice contracts and one large provider group with a history of accepting capitation to care for elderly Medicare beneficiaries.

We selected the four MCOs after developing a list of organizations that had innovative programs for seniors with multiple chronic conditions or disabilities. We developed the list using reports in the literature, suggestions from the project’s Technical Advisory Group, and the authors’ knowledge of the industry. In selecting the four to study, we looked for a mix of organizations in terms of plan type, Medicare + Choice payment level, profit/nonprofit tax status, and geographic location. All organizations also had to have more than 10,000 elderly Medicare beneficiaries and several years’ experience with special programs for seniors.

Once we selected the MCOs, we identified three groups of seniors who had severe limitations or multiple chronic conditions and who had been identified as high risk by their MCO. These groups include elderly beneficiaries being served by an MCO’s care management program, those who had attained advanced age (more than 84 years old), and those who had experienced a recent hip fracture or stroke. While these three groups do not constitute or represent all high-risk seniors, they provide a convenient way of illustrating the experiences of seniors whose high-risk status is known to their MCO.

We conducted the case study site visits from December 1997 through October 1998, and surveys from March 1999 through December 1999, with a second round of interviewing for the subsample of seniors with hip fracture or stroke conducted from October 1999 through July 2000.

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