Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. A. Focus Groups of Beneficiaries with Hip Fracture or Stroke


The focus groups of seniors who experienced hip fracture or stroke reported having intensive interactions with the MCOs and readily provided opinions on the nature of the services received. While the participants in the hip fracture and stroke focus groups were generally satisfied with their care, their discussion concentrated on the costs of care and on whether the level of care was appropriate. In addition, they raised many issues that reflect broad trends in the health care system rather than unique features of the case study MCOs.

For example, many of the focus group participants complained about the length of their hospital stay and the timing of their hospital discharge:

I just want to know why, when you’re in the hospital, they can’t continue your physical therapy there. They told me the insurance doesn’t allow it, and the only reason I stayed longer in the hospital--which was a blessing to me--was that I was keeping a low-grade temperature so they wouldn’t release me.

They wouldn’t keep her in the hospital for observation. Now, to me, an 87-year-old lady that has blood in her bladder and has brain damage and has to be put on medication to control seizures has no right going home at three in the morning with somebody like me who is not a medical person.

Is there a limit that they can keep you in the hospital for something other than being close to death? . . . I was in the hospital for four days. And then they moved me over into a rest home or whatever, a care center. And I was having trouble at that time because of my heel. . . . I mean, it doesn’t make any difference to me. But it seemed to me that they seemed to be in some sort of hurry to get you out of the hospital.

These concerns about hospital length of stay show how the general trend toward shorter hospital stays can create anxiety among seniors with serious health problems. Efforts to shorten hospital stays have been common in the Medicare fee-for-service and managed care sectors for years. Yet for many of the seniors in our focus group, the discharges seemed too quick for the patients and their caregivers. Some of this concern may reflect the seniors’ expectations for hospital lengths of stay. These expectations may be based on personal experiences from prior decades and may therefore be unrealistic for current practice. Concern may also stem from anxiety that a senior’s spouse might have about their ability to provide any required home care for someone discharged from the hospital with a serious illness. Even when adequate home-health care is available, many spouses will be asked to help with patient monitoring and provide some assistance with activities of daily living. Such care may be difficult and quite anxiety provoking for many seniors. Discussions with the focus group participants also suggested that the discharges occurred at a time when the seniors and their families were confused about their conditions, expectations for recovery, and treatment plans. They were adjusting to a major, potentially life-altering injury, and that made it hard for them to understand the options. As the wife of a man who was still recovering from his stroke at the time of our focus group put it:

I think maybe he could have stayed [in the hospital] longer. I think one of us should have said no way. But you see, we don’t know. This is a new experience. Nobody tells you anything. You have to go by-guess-and-by-golly. Once he was out, we did have a therapist. They were very good about sending a therapist in. She first came two days a week, and now she’s coming three days a week.

These comments highlight a concern of many focus group participants that they did not understand their course of treatment, particularly when they were being transferred from one treatment setting to another. Their uncertainty may reflect the fact that many seniors, particularly those over 85 years old, have difficulty understanding medical care options and may require individually tailored explanations (Gold and Stevens 2001). This uncertainty seemed to raise anxiety among the seniors and may have also reduced the effectiveness of some treatments.

For the most part, participants in the hip fracture and stroke focus groups appeared to be pleased with the frequency and quality of the rehabilitative therapy they received in the MCOs. This therapy was received largely in nursing homes, not rehabilitative hospitals, situation that previous studies have shown is common among MCOs (Retchin et al.). The paucity of complaints about the rehabilitative experience of our focus group participants suggests that the MCOs were successful in their efforts to screen nursing homes for their ability to deliver appropriate rehabilitative care (Kramer 1996).

In addition to the comments on hospital and short-term nursing home stays, home care services drew some favorable comments. One man who was helping his wife recover from a hip fracture said:

We were very pleased going into this, because we made phone calls to the plan, and they set up the date and got the referrals and everything. Everything was in order. They sent a nurse beforehand to take blood, temperature, blood pressure. They sent another therapist. She came and looked around. We live on all one story, but then we have a basement. . . . She came to see the setup of the house and everything. We thought this was really wonderful.

Many participants in focus groups for hip fractures and strokes also commented on the ability to secure durable medical equipment. These are especially germane to the care of these patients, because of their needs for adaptive devices to ensure that the home environment is safe. For some, the ability to get these items was selective:

When we were in what they call the occupational therapy in the hospital, they showed you how to get in and out of the tub with a bench that you had to buy. [The plan] did not pay for that, so I had to get a bench. They ordered the commode because of getting up and down on the toilet, and of course you had your walker and a cane, which were provided for by the plan.

Clearly, many participants in the focus groups felt that one of the major benefits of the MCOs was the reduction in costs. Since many stroke patients require multiple medications, usually to control hypertension and other cardiac comorbidities, this appeared to be a special attraction enjoyed by stroke patients in the MCOs that provided prescription benefits. Furthermore, because of the many expensive resources used by these patients, the absence of a deductible was also appealing:

Well, I wasn’t too keen on going into [the MCO], because of the having to get a referral all the time, but now I like it. And looking back over some of my records, I remember when you would get your “this is not a bill” from Medicare, where it would say you have met so much of your deductible.

We’ve been very pleased with the fact that we’ve gotten prescriptions, and that has been wonderful. Now I’ve been talking to my neighbor. She pays $70 for a prescription, and I said, “Marie, you’ve got to get into this [MCO].” I’m very thankful for that, very thankful.

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