Academic journal article Health Care Financing Review

Social/health Maintenance Organization and Fee-for-Service Health Outcomes over Time

Academic journal article Health Care Financing Review

Social/health Maintenance Organization and Fee-for-Service Health Outcomes over Time

Article excerpt


The utility of LTC for functionally impaired, community dwelling elderly is well documented. In-home services (for meal preparation, shopping, laundry, grooming, and dressing) and out-of-home services (such as adult day care, recreational, physical, and occupational therapy) improve client and caregiver lives (e.g., Kemper, 1988). The value of case management (i.e., needs assessment, care planning, coordinating and monitoring of services) is also evident. Though improving client and caregiver outcomes, however, these services do not appear to reduce costs-possibly due to methodological factors (e.g., defining their cost effectiveness relative to institutional care) (Kemper, 1988; Weissert, Cready, and Pawelak, 1988; Zawadski, 1984). Institutional costs are limited by State Medicaid programs and may be insufficient to bring about therapeutic innovations or to prevent quality-of-care problems (e.g., decubitus ulcer, malnutrition, pneumonia, or urinary tract infection [UTI]) (Brandeis et al. 1990; Braun, 1991; Dontas et al., 1991; Fiatarone et al. 1990; Gloth et al., 1991; Gross, 1988; Pinchcofsky-Devin and Kaminski, 1987).

Consequently, an alternative model for delivering LTC to community populations, the S/HMO, was developed. It was hoped that LTC, provided in a capitated system (as it is in a S/HMO), might improve cost effectiveness and outcomes. A Health Care Financing Administration (HCFA) demonstration of S/HMOs started in January 1985. S/HMOs were to:

* Provide hospital, physician, home health, extended benefit (e.g., eye glasses, hearing aids, drugs) and LTC services (e.g., nursing home, homemaker, and transport) to voluntarily enrolled clients paying a monthly premium.

* Use case managers to determine eligibility for, and select, LTC services. Access is limited by disability criteria and coverage limits.

* Serve both impaired and unimpaired elderly to maintain health and function.

* Be reimbursed by capitation payments from pooled Medicare, Medicaid (for eligible enrollees), and member premiums. S/HMOs assumed risk for all costs after 30 months. Integrated funding and financial risk are incentives for cost control and service flexibility (Leutz et al., 1985).

Some S/HMO features complicate the evaluation process. Because enrollment is voluntary, and marketability important, persons with specific health attributes can self-select into S/HMOs. Thus, a randomized study design could not be used. Statistical controls for health differences between S/HMO enrollees and members of comparison FFS samples are necessary. Additionally, the LTC provided by S/HMOs is available to persons in FFS. That is, the intervention depends on the degree to which S/HMOs make LTC accessible and not on its presence or absence. Variation in interventions makes comparisons of S/HMO and FFS outcomes complex. Here we focus on one outcome--the effect of being in a S/HMO on a person's functioning, relative to being in Medicare FFS, controlling for initial health and mortality. In this analysis we do not deal with cost issues, as they are treated in other reports.

Comparing outcomes longitudinally between S/HMO enrollees and FFS samples is difficult because of systematic health changes, mortality, and sample loss. For example, in the National Long-Term Care Channeling demonstration, the effect of increased access to case management (both with and without payments for additional services) was evaluated in 10 sites during an 18-month period. Persons with impairments were selected for the study and randomized into one of four groups (i.e., case and control groups defined for two interventions). Differences were found on baseline interviews in case and control response rates (10 percent higher for cases), response times (cases responded 5.4 days faster), and willingness (cases, on average, required 29 percent fewer contacts). Timing was important in assessing hospitalized or institutionalized persons (Brown and Mossel, 1984). …

Search by... Author
Show... All Results Primary Sources Peer-reviewed


An unknown error has occurred. Please click the button below to reload the page. If the problem persists, please try again in a little while.