Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. D. Summary


Overall, we found that the case study MCOs produced very high levels of satisfaction among a group of high-risk seniors. This is consistent with our efforts to study MCOs with strong reputations. It also contrasts sharply with prior findings for the Medicare + Choice program, where these seniors have traditionally reported lower-than-average satisfaction. Thus, the case study shows that MCOs can produce strong results for this group.

In looking at some of the factors that influence overall satisfaction, we noted instances where the benefit package and the structure of an MCO’s physician network made a difference in plan members’ experience. Many high-risk seniors in our sample, like many managed care enrollees in general, enrolled to save money. Savings arise because the MCOs’ Medicare contracts often covers things for which the beneficiary would have to pay in the fee-for-service sector, including co-payments for hospital care and in some cases prescription medications. In our sample, we saw somewhat lower satisfaction with out-of- pocket medical expenses among the seniors at Aspen. The Aspen sample was enrolled in the Medica Health Plan, which received lower Medicare + Choice rates than Keystone East or Kaiser Colorado. As a result, the benefit and premium package Medica offered was not substantially different from that available to seniors who had fee-for-service Medicare and a supplemental policy. We also found evidence that seniors were more satisfied with their choice of providers in Keystone East, an IPA with a very large network, than in the two group models.

While the seniors in our sample seemed happy with their choice of plans, sizable minorities had no concrete plan for addressing dissatisfaction with medical care or coverage decisions. Some of the lack of information may be a product of their generally high satisfaction levels. Seniors who are happy with their care and coverage may not bother to find out how to file a complaint effectively. Nevertheless, to the extent that these groups represent a broader population in all Medicare + Choice program, policymakers should consider way to promote their access to information and their ability to act on that information.

We also noted that the care management offered by the case study MCOs was often not salient to seniors. This does not mean that the care management was ineffective in coordinating care, but it does imply that the care management program will not be a major ongoing source of information, monitoring, and advocacy for the seniors. Less than half the seniors who were identified on MCO-provided lists as having been enrolled in care management said that they knew they were in care management. This lack of salience probably reflects the focus of the MCOs’ care management programs, which emphasized short-term assessment, care coordination, and referral to community-based service agencies. Given this structure, it is not surprising that many of the seniors did not remember their prior care management at the time we interviewed them. The lack of salience also reflects the difficulty in getting the care manager to stand out from the mix of other nurses and providers who care for the high-risk seniors.

In general, the levels of satisfaction were high among all three of our risk groups, seniors with advanced age, seniors in care management programs, and seniors with a recent hip fracture or stroke. However, seniors with a recent hip fracture or stroke tended to be somewhat less satisfied on some measures, although most of those differences were not statistically significant. In the next chapter, we examine the experiences of this group and the ways in which the MCOs attempted to meet their organizationally complex care needs.

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