The inadequacies of our fragmented acute and long-term care financing and delivery systems have been well recognized for many years. Yet over the past two decades only a very small number of "boutique" initiatives have been able to improve the financing and the delivery of care to chronically ill and disabled populations. These initiatives share most of the following characteristics: prepaid, risk-adjusted financing; integrated Medicare and Medicaid funding streams; a flexible array of acute and long-term benefits; well-organized, redesigned care delivery systems that tailor these benefits to individual need; a mission-driven philosophy; and considerable creativity in engaging government payers. The experience of these "boutiques" illustrates both the obstacles to, and the opportunity for, meaningful, widespread care delivery reform for vulnerable chronically ill populations.
The authors evaluated a managed care model developed for use by community-based providers to improve health care outcomes for low-income Latinos with disabilities and chronic illnesses. Through this model, Medicaid enrollees with special health care needs were identified and received enhanced primary care, on-site mental health and addiction services, care coordination, and support services based on their levels of need. The goal of the demonstration was to determine whether capitation would be a catalyst to transform typical primary care delivery processes to provide enhanced, culturally competent care to patients with complex health care and psychosocial needs. Despite a significant investment in outpatient services, the intervention was cost effective due to a dramatic decline in inpatient care for a few enrollees. For most enrollees, care was slightly more expensive due to enhanced outpatient medical and mental health care. Enrollees expressed high satisfaction with the intervention.
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