Solved: Please read the following Public Policy Institute Report for the AARP on the evaluation

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:

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Solved: Please read the following Public Policy Institute Report for the AARP on the evaluation
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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.


Students reponse:

Compared to other Medicare risk plans, S/HMOs provided improved benefits for beneficiaries but it was more expensive (approximately 15-30% more) but there were no reliable proof that they were advantageous for the beneficiaries according to a demonstration project conducted by Medicare (“Evaluation,” 2002).

Although case managers were successful in obtaining additional benefits for patients/beneficiaries they would not have acquired themselves, there were problems and concerns with S/HMOs. The end result just did not provide enough to justify the high cost of the plans. Researchers suggested further work but they found that directing activities to those with certain conditions maybe beneficial and that case managers played a role in expanding beneficiaries’ available treatment or care choices and benefits (“Care Management,” n.d.). Case managers were successful in monitoring and maximizing beneficiaries’ benefits.

Expert Answer

S/HMOs provide benefits are comparatively more including non covered services like legal aid, social security entitlements and housing. It is reimbursed on capitated basis from funding sources, Medicare and Medicaid but I don’t think it is expensive than other plans since it is providing acute and long term care to low income elderly persons for a long time. It covers more benefits than other plans and case managers but there is no data available on Medicare savings due to S/HMO case management activities. The case managers were successful in monitoring and maximizing benefits but there was variability in services. According to review on evaluation report there was opportunity to improve policies and processes for physician presence and involvement in post acute care planning. More activities were needed for streamlining assessments and coordinating Medicare skilled care for community benefits. The care management costs are modest administrative cost, but there is no data on overall savings. But since S/HMO is based on capitated reimbursement there is no significance for cost data. The research has no conclusion but it points for further work that includes focusing the activities on beneficiaries with certain conditions for more benefit. It also points that patients do not get benefits from efforts of care managers for care management in post acute care. . In my opinion, the student review covers the important points discussed but need to focus more on the benefits. I couldn’t find the reason for stating S/HMO as more expensive in the review after reading the report.

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