Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. CHAPTER III. CARE NEEDS OF HIGH-RISK SENIORS


Care systems for elderly Medicare beneficiaries with disabilities and chronic illnesses must be able to address a variety of special needs and characteristics. In Chapter I, we used the acronym VIP--variability, impairments, and providers--to organize these needs and characteristics into three broad categories.

We use descriptive information from our site visits, focus groups, and survey to illustrate the VIP characteristics for a special sample of high-risk seniors. In particular, our selection process means that we focused on a subset of high-risk seniors enrolled in well-regarded and innovative managed care plans. Furthermore, the high risks of these seniors are, in general, known to their managed care organization (MCO) because they were selected from three types of lists that the MCOs generated: (1) lists of seniors in the MCO’s care management program; (2) lists of organization members who have attained an advanced age (85 or older); and (3) lists of seniors who have experienced a recent hip fracture or stroke. Thus, we suspect that our sample of high-risk seniors is likely to have more favorable experiences than other such seniors in Medicare + Choice plans or in Medicare fee-for-service. Furthermore, our survey sample was heavily weighted toward the largest of our case-study sites, Keystone East. Overall, 72 percent of our survey sample comes from that organization, so our tabulations disproportionately reflect the experiences of the Philadelphia-area high-risk seniors enrolled in Keystone East.

There are two important caveats to keep in mind with respect to the characteristics presented in this report. First, while we focus on high-risk seniors in managed care, most of the special characteristics we identify also pertain to high-risk seniors in the Medicare fee- for-service sector. We hope that our findings will help all organizations that seek to serve high-risk seniors, not just MCOs. Second, while we often focus on challenges high-risk seniors face, this should not mask the great capacity, courage, and resiliency seniors generally exhibit when dealing with health and functioning problems.

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