Discussion: Care Management in the S/HMO Demonstrations

Please read the following Public Policy Institute Report for the AARP on the evaluation of S/HMOs. Based on the following summary do you find any special worthwhile need or benefit from Social Health Maintenance Organization s(S/HMO)? Please post your opinion before the end of the Module.

Potentially relevant research findings emerged from evaluations of the Social Health Maintenance Organization (S/HMO) demonstration projects. These projects, which have been ongoing at various sites since 1985, provide acute and long-term care to low-income elderly persons. The S/HMOs are reimbursed on a capitated basis, from a combination of funding sources, especially Medicare and Medicaid. The operational aspects of S/HMO programs differ across the projects, and the programs have each evolved separately over the years. Care management has figured prominently at virtually every site:

The S/HMOs have used care management approaches to assess chronic care needs and authorize services for enrollees.
Care managers have assisted enrollees in obtaining non-covered services and benefits, such as Social Security entitlements, legal aid, and housing.

An early evaluation report observed that “the case managers have been able to monitor and maximize benefits with considerable success.” But the evaluators found variability “in the extent to which the acute and long-term services had been integrated to provide an effectively coordinated continuum of care for impaired elderly.” Subsequently, other reviewers of early S/HMO results have called for better links between S/HMO care management and acute and post-acute care. Two themes emerge from specific suggestions: first, there are opportunities to improve policies and processes for physician presence and involvement in post-acute care planning; and second, more activities should be directed at streamlining assessment and coordinating Medicare skilled care with related “community care benefits.”

The data on care management costs are relatively positive in terms of total S/HMO costs, which are financed by Medicaid as well as Medicare. The care management function is reflected as a modest administrative cost, or even as a revenue center to the extent that needs assessments result in Medicaid eligibility determinations. However, there is no documentation of overall Medicare savings attributable to S/HMO case management activities. Further, since the S/HMO demonstrations are studies in capitated reimbursement, cost data are not particularly useful in the context of fee-for-service Medicare.

HCFA’s research of care management in Medicare and the S/HMOs is generally inconclusive. However, the findings do point in specific directions for further work. First, the weight of the available evidence indicates that Medicare care management holds the most promise when the activities are highly focused, especially if centered on beneficiaries with specified conditions, such as congestive heart failure. Second, while care management in post-acute care may not reduce Medicare costs, the patients nonetheless benefit from efforts of care managers to maximize their care options.