Case Mix Controlled Service Use and Expenditures in the Social/Healt Maintenance Organization Demonstration

Newcomer, Robert; Mantón, Kenneth G.; Harrington, Charlene; Yordi, Cathleen; Vertrees, James C.

doi:10.1093/gerona/50a.1.m35

Cited by 27 publications

(15 citation statements)

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“…There is, however, general agreement that the Social HMO model fell short of expectations during the initial 3-year demonstration phase (1986-1989) (1). Nevertheless, the sum total of findings suggests several outcomes in a positive direction: 1) the majority of enrollees expressed satisfaction with the program, and family caregivers found its long-term care features very helpful (18,19); 2) while no overall cost savings were observed, one of the sites provided more services to the most impaired group for less cost than the traditional fee-for-service sector (20,21); 3) although the sites did not show consistent positive effects with respect to institutional utilization, one of the Social HMOs found that its elderly enrollees spent 25 percent fewer days in nursing homes as compared to elderly members of conventional, medically-oriented HMOs (22)(23)(24); and 4) overall, the demonstration established the feasibility of integrating responsibilities for the financing and delivery of acute and long-term care in one organizational entity, though this proved to be a complex undertaking (1).…”

Section: Social Health Maintenance Organization (Social Hmo)mentioning

confidence: 99%

The quest for integrated systems of care for frail older persons

Kodner

2002

Aging Clin Exp Res

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The challenge of an increasing elderly population, particularly with respect to frail older persons in need of long-term care, has coupled with ever-present budget constraints to make the financing, organization and delivery of elder care a major priority in North America, Europe and elsewhere in the developed world. Despite obvious cross-national differences in health and social care arrangements for the frail elderly, evidence of poorly coordinated services, disjointed care, less than optimum outcomes, system inefficiency, inadequate accountability, and uncontrolled costs can be found in all countries. There is a growing belief that more comprehensive approaches are needed to effectively address these problems. One such strategy, so-called integrated systems of care, shows great promise. The author critically examines the concept of integrated systems of care for the frail elderly, including the theoretical benefits and drawbacks of the model. At the policy and practice levels, descriptions are presented of, and evidence and lessons are summarized from a representative sample of such projects in the US (Social HMO and PACE), Canada (SIPA), Italy (Rovereto) and Australia (Coordinated Care Trials). The introduction of prototypes such as these raises a number of significant issues for policymakers, payers, providers, consumers and researchers. These are briefly examined in concluding remarks on the important potential of integrated systems of care for vulnerable older people.

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Section: Social Health Maintenance Organization (Social Hmo)mentioning

confidence: 99%

The quest for integrated systems of care for frail older persons

Kodner

2002

Aging Clin Exp Res

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“…The federal evaluation failed to evaluate the effect of CC and service coordination on nursing home use, Medicaid expenditures, or functional status. Rather, the core evaluation studies of outcomes used a synthetic case mix grouping method that did not pay attention to who actually was eligible for or used the benefit (Newcomer, Manton et al, 1995), and there were additional methodological shortcomings on these studies (Leutz, Greenlick et al, 1994). One evaluation study did study outcomes for those targeted for expanded care and found that informal care for frail Social HMO members was maintained better than such care for the fee-for-service frail.…”

Section: Case Management Utilization and Costs In The Social Hmomentioning

confidence: 99%

A Limited Entitlement for Community Care

Leutz

Capitman

Green

2001

Journal of Aging & Social Policy

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The goal of this paper is to show how members of three Social HMOs use a limited entitlement for community-based long-term care to meet their needs and solve their problems. The paper is based on in-home interviews with 48 aged Medicare beneficiaries who joined Social HMOs and are eligible for the entitlement. Members' experiences with case management (called service coordination), benefits for covered services, and cost-sharing requirements are explored. Members (and their informal caregivers) are found to have complex lives, into which community care fits (or does not fit) in varied ways, depending on preferences, experiences with providers, informal care, financial resources, and other factors. The paper provides insights into what kinds of problems people want to solve and how community care systems can be better designed to empower service users to solve them.

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“…The first social health maintenance organisations gave disappointing results,21 but a second generation is more ambitious, attempting to identify clinical problems early and to intervene efficiently with expert interdisciplinary teams 22…”

Section: Innovations In Chronic Carementioning

confidence: 99%