Caring for the Disabled Elderly: Who Will Pay?

By Alice M. Rivlin; Joshua M. Wiener et al. | Go to book overview

Chapter Six
Social/Health Maintenance Organizations

A social/health maintenance organization is an extension of the concept of a health maintenance organization. Enrollees in a health maintenance organization (HMO) pay a fixed fee in advance (called a capitation fee) that entitles them to a broad range of health services delivered almost entirely by physicians, hospitals, and other providers affiliated with the HMO. In contrast to the fee-for-service system, in which providers are paid separately for each service supplied, an HMO has an incentive to ensure that enrollees get appropriate care at the lowest cost and are not hospitalized when less costly home or outpatient care would be just as effective. HMOs lower health costs for their enrollees by reducing hospital use and substituting ambulatory services. 1

A social/health maintenance organization ( S/HMO) broadens this approach by covering long-term care services not normally included in health maintenance organization benefits. By consolidating acute and long-term care services and payment, S/HMOs seek to create a more efficient and coordinated system of care for the elderly. By achieving acute care savings, they can decrease the incremental cost of long-term care services; that is, reduce premiums and improve affordability for the lower-income elderly. With member use channeled to lower-cost services by cost-conscious case managers, a much richer array of home care services can be offered than in the typical long-term care insurance policy. Although discussed here as a private sector financing mechanism, S/HMOs could operate as a financing and delivery system reimbursed by a public insurance program.

The difficulty in evaluating S/HMOs is that they are more a concept

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