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

01/01/2002

Despite the complexity of health care for high-risk seniors, very few report not receiving needed help with ADLs or IADLs. Table III.7 indicates that, while 2.5 and 2.7 percent reported not receiving needed help bathing and transferring, less than 2 percent reported unmet needs for the remainder of the ADLs. Unmet needs were slightly more common for IADLs than for ADLs. This differential may reflect the greater availability of services to deal with the more serious ADL limitations.

Looking at unmet needs alone provides little cause for concern, but adverse outcomes suggest that there is room for improvement. For example, among high-risk seniors who needed help changing their clothes, approximately 15 percent said they could not do so as frequently as they wished because of a lack of assistance. Approximately 14 percent of those who felt they needed help with bathing reported that they could not bathe as often as they would have liked because they lacked needed help. Furthermore, five to six percent of the seniors in our sample reported that they went hungry because they did not receive needed help preparing a meal or eating.

TABLE III.7. Unmet Needs of High-Risk Seniors
(Percentages and Their Standard Errors)
    Survey Sample  
Needs Human Help but Does Not Receive Help with:a
   ADL
      Bathing 2.5 (0.6)
      Eating 1.1 (0.3)
      Dressing 1.6 (0.5)
      Transferring 2.7 (0.6)
      Toileting 0.9 (0.4)
   IADL
      Preparing meals 2.6 (0.6)
      Doing light housework or making bed 5.8 (0.9)
      Managing money 2.8 (0.7)
      Using telephone to call physician 1.8 (0.5)
      Getting around inside home 2.4 (0.5)
Adverse Outcomes Among Those Who Needed Help with Activity, Regardless of Whether They Got Helpb
   Experienced discomfort because unable to eat when hungry and did not have needed help preparing meal 5.8 (1.6)
   Unable to call physician because did not have needed help using the telephone 3.7 (1.0)
   Unable to bathe as often as liked because did not have needed help bathing 14.4 (1.9)
   Unable to change clothes as often as liked because did not have needed help changing clothes 14.8 (3.3)
   Unable to eat when hungry because did not have needed help eating 5.4 (2.6)
   Unable to get out of bed or chairs because did not have needed help transferring 14.3 (2.7)
SOURCE: Telephone survey of 1,657 high-risk seniors from three managed care organizations, conducted between March and December 1999 by MPR.
NOTE: Values are percentages and are weighted to represent the population and correct for nonresponse. Standard errors are in parentheses. None of the variables in this table had more than a 5 percent nonresponse.
  1. Sample consists of 1,399 community residents only.
  2. Sample consists of beneficiaries who reported needing help with a given activity.

While the presence of adverse outcomes due to unmet need among high-risk seniors is cause for concern, there are several important points to consider when examining these outcomes. First, as stated earlier, Medicare + Choice plans with risk contracts are required to provide only the benefits specified in their risk contract, which generally focus on those services that are “medically necessary.” Assistance with ADLs or IADLs is often not categorized as such and so would not be covered (Ireys et al. 1999). Second, there is evidence of widespread unmet need among the general elderly population, including those in the Medicare fee-for- service sector (Allen and Mor 1997; and Institute for Health and Aging 1996). Thus, the levels found for our sample of high-risk seniors are not substantially out of the ordinary.

We now turn to the ways in which our case-study managed care organizations tried to address the variability, impairments, and organizationally complex set of providers that characterize high-risk seniors.

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