Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. CHAPTER VI. MANAGED CARE EXPERIENCES OF SENIORS WITH RECENT HIP FRACTURE OR STROKE


Among high-risk seniors, those with a recent cerebrovascular accident (CVA, or stroke) or hip fracture represent a particularly relevant group in the study of organizationally complex care. Both conditions trigger a cascade of events that can lead to multiple transitions between home, hospital, and institutional settings and involve treatments from many providers. While both conditions are precipitated by acute events, they often lead to long- term disabilities. In addition, the nature of their treatment shifts over time, beginning with an emphasis on acute medical care because of a sudden, catastrophic event, and shifting to an emphasis on chronic therapy, rehabilitation, and in some cases, long-term custodial support. Managed care organizations (MCOs) appear to offer opportunities to reduce the medical costs of this care while still producing outcomes comparable to those observed in the Medicare fee-for-service sector (Retchin et al. 1997; and Kramer 1996). They may also be able to foster access to community-based social services that can promote functioning and independence for seniors with one of these conditions.

CVAs are common, life-threatening events among elderly people, and they can lead to chronic disabling consequences (Alter et al. 1986). With disability and loss of health status following the acute event, patients with CVAs often lose their functional independence and require institutionalization. Thus, the post-acute rehabilitation of patients with CVAs, and the subsequent optimization of functional status, is of paramount importance to these patients. While the urgency of hospitalization arises from the need for diagnostic specificity, stroke patients frequently require expensive resources for post-hospital care. There is also some evidence that post-hospital services have been performed less often, or less intensively, for some MCO patients with strokes (Retchin et al. 1994). This has led to concern that this type of decline in service, or other restraints on clinical care that may result from financial disincentives, could lead to reduced functional recovery for beneficiaries with CVAs (Webster and Feinglass 1997).

Hip fractures are associated with the highest and most well-defined rates of morbidity and mortality among all fractures related to osteoporosis and falls. Not only are they costly to treat, but the overall burden of illness due to these fractures could grow as a result of the increasing prevalence of osteoporosis and the rising incidence of falls among seniors. The lifetime risk of a hip fracture is 16 to 18 percent among white women and 5 to 6 percent among white men. At the age of 80 years, approximately 20 percent of women have suffered a hip fracture (Kannus et al. 1996). The burden of illness for those with hip fractures is large. Many have prolonged rehabilitative stays, on average greater than two months in specialized units (Schurch et al. 1996). Mortality is high, with one-year mortality estimated at approximately 24 percent. Only 50 percent of patients with hip fractures regain the mobility and independence they enjoyed 12 months earlier Costs are also high, especially during the first year (Johnell 1997). The largest costs are attributable to hospitalizations, nursing home stays, and rehabilitation services (Brainsky et al. 1997). Total U.S. health care expenditures attributable to osteoporotic fractures in 1995 were estimated at $13.8 billion, of which approximately 63 percent were attributable to hip fractures (Ray et al. 1997), and these costs are likely to continue to rise. Within 50 years, the cost of hip fractures alone in the United States has been estimated to exceed $240 billion (Lindsay 1995).

As in many other areas, we found that our case studies of the four MCOs revealed a number of innovations used by patients with a stroke or hip fracture. However, those innovations generally were not designed specifically for seniors with these two conditions, nor did they substantially alter the overall approach to treating hip fractures and strokes. The innovations generally reflected the organizations’ efforts to deliver some types of care in skilled nursing facilities rather than in hospitals. They also reflected the organizations’ use of care management services to foster referrals to community-based social service agencies.

Our site visits also found that the innovations of the group model organizations (Aspen and Kaiser Colorado) were different from those of the IPA model organizations (Keystone East and HMO Oregon). In particular, the group model organizations made a greater effort to arrange for postacute care to be delivered by a small set of selected skilled nursing facilities. This included requiring these facilities to meet certain quality and service standards, such as being able to provide therapy six days a week. The two group models in our study also used a hospitalist-type approach for delivering physician services in the hospital. In contrast, the IPA models appeared to make less use of network restrictions. Keystone East, however, tried to promote continuity of care by providing financial incentives for a senior’s primary care physician to manage any hospitalizations.

As noted in Chapter II, we collected data from site visits, focus groups with seniors and providers, and a survey. Our analysis of how seniors with hip fracture or stroke fared in our case study MCOs draws on all these sources. In particular, it uses information collected during focus groups with seniors (or their spouses) who had experienced a hip fracture or stroke, and with primary care physicians in the MCOs’ networks. Further, Chapter V reports on levels of satisfaction and dissatisfaction among patients with hip fracture or stroke. These quantitative data from the surveys are particularly worth noting in the context of the findings that follow from the focus groups of patients with hip fracture or stroke.

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