Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. E. Conclusion


The lack of management programs specifically designed to assist seniors with a recent hip fracture or stroke appears to reflect several structural limitations at the case-study MCOs. First, the two IPA model MCOs were still fairly new at the time of our visits: one had operated its Medicare risk program for only three years and another for only four, even though they had both served commercial populations for more than a decade. It may take organizations longer than this to develop the expertise, data, and financing required before they are likely to develop new programs for treating conditions such as hip fracture or stroke. In fact, at one of the MCOs, an executive administrator lamented (at the time of our visit) that it was only recently that the senior management had recognized that the revenues and costs associated with their Medicare risk program were disproportionate to the size of enrollment. Previously, senior management had not focused often on their Medicare products, because the commercial population in this MCO dwarfed their Medicare risk enrollment. Difficulty in getting senior management attention can limit the ability of an organization to obtain the resources required to design and implement innovations, such as specific disease management programs for the care of Medicare beneficiaries with strokes or hip fractures.

Management programs targeted specifically to seniors with a hip fracture or stroke seem particularly promising because it is easy to identify an inception point. Both of these events can are well defined and the affected patients can typically be identified in hospital emergency rooms. While an ideal MCO would take steps to reduce the probability of these events in the first place, such efforts are unlikely to prevent them all. Thus, there will continue to be a need for managing the delivery of services and assisting patients and their families following a hip fracture or stroke. A care management program could rely on the existing MCO hospital admission and discharge systems to identify these cases and start planning for their recovery. The critical issue for these patients would be followup to ensure continuity in the postacute settings and support for the patients and their families to deal with any long-term consequences of their event.

The care transitions inherent in the treatment of hip fracture or stroke also make these conditions good candidates for targeted care management. Each time a patient moves between the community, hospital, or nursing facility there is the potential for problems. Complete medical records may not be available to a physician. A facility-based physician may not have sufficient time to develop a full understanding of a seniors capabilities and attitudes. Hand-offs between providers may be inadequate leaving patients confused, or in the worst cases, without required services. For example, a senior might be sent home without sufficient training for them and their spouse to perform the required monitoring and care. Care management could address many of these problems by providing more continuity to the care, education to patients and caregivers, and help to monitor patients’ health and ability to comply with treatment recommendations.

Clearly, our sample of MCOs, particularly the group models, sought to substitute skilled nursing care for the more recuperative aspects of hospital care, by discharging patients early. To ensure quality, they were meticulous to include in their networks skilled nursing facilities that were capable of delivering the required care. Moreover, since it is difficult for physicians, hospitals, or patients to assess the quality of nursing homes, the MCOs supplied a vital missing element in the fee-for-service environment. Therefore, the facility screening and quality monitoring of skilled nursing facilities by the MCOs appears to offer tangible advantages over an unmanaged system. Last, several of the MCOs organized dedicated groups of providers that were assigned exclusively to skilled nursing facilities in the networks constructed by the health plans. Again, this appeared to be a special innovation that may have helped in the difficult coordination of care of these vulnerable subgroups across the transition from hospital-to-rehabilitative settings.

View full report


"constrai.pdf" (pdf, 32.58Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®