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.
PROVIDE A RESPONSE AND REMARKS TO THIS STUDENTS DISCUSSION POST BELOW, BASED ON YOUR UNDERSTANDING:
To be frank, I believe Social HMOs are very worthwhile for the sake of the future of health care. The reason I say this is because of the continued growth of the elderly population. Baby boomers are getting older and will ultimately be responsible for more than doubling the number of Americans over the age of 65 from 46 million to 98 million by 2060 (Mather, 2016). The elderly often has one or more chronic conditions and account for much of the U.S. health expenditures. With an increase of elderly individuals, comes a larger demand for healthcare providers. Unfortunately, the odds of having an adequate number of physicians to people in the future are not good. S/HMOs can help mitigate this problem.
While there is no proof or documentation of Medicare savings as a result of S/HMOs, there are significant benefits to be had. Firstly, S/HMOs offer increased patient satisfaction (Gowing, 2016). Additionally, patients have been found to take a more active role in their own care through self-management and advance care planning with case managers involvement (Gowing, 2016). Patients being more active and compliant in their health care with chronic conditions is very powerful and ultimately cost-saving. Case managers in one American study made themselves available during extended hours and weekends. They were also flexible with telephone calls and scheduling site appointments contrary to formal providers (Kim, 2016). At the end of the day, case managers can be part of the solution to the increased demand of healthcare in baby boomers. They may not be able to completely replace the care physicians offer, but they can certainly help!
Social Health Maintenance organisations provide healthcare facilities to low income elderly persons. Since these category cannot afford high end treatments these organizations help them in getting the healthcare facilities. They are reimbursed by Medicare and Medicaid . The s/HMO have utilised the care management approaches which benefits both the patients and the caregivers. By providing proper care facilities patients can be transitioned to home and this reduces the strain on hospital which can accomodate other patients. It encourages patients to take active part in their health .Hence inspite of the fact that there are not enough savings attributable to care management activities of s/HMO but still the benefit has to be looked in a larger arena. Reducing the pressure on already less number of doctors available and limited facilities available to elder and poor people , s/HMO are playing a vital role.
The student’s response is very much in order. The response properly states the need for s/HMO since the elderly population would rise and they need to be treated well. Not all the health needs could be met at the hospital by qualified doctors hence it is necessary for s/HMOs to provide proper acute and post acute healthcare facilities. The student also highlighted the major benefit that care managemet approaches have. It emphasises the patient to actively participate in their own health by working together with care managers. This can greatly reduce the patient ‘s need to be admitted in hospital and future hospital costs.
One further points which can be added is :
1) Altough we cannot deny the benefits of s/HMO but there shall be better connectivity between care management and acute and post acute care. The policies and procedures shall be improved so that work can be done more cost effectively. The money shall be effectively utilised to the largest extent possible. This might help in savings as well. Overall the s/hmo are required for the better health care facilities and increased reach among the poor and elderly.