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Implementing the second generation social health maintenance organization.

R Newcomer1, C Harrington, R Kane

  • 1Department of Social & Behavioral Sciences, University of California, San Francisco 94118, USA.

Journal of the American Geriatrics Society
|July 14, 2000
PubMed
Summary

The Social Health Maintenance Organization (HMO) demonstration successfully integrated geriatric care, improving health outcomes for at-risk Medicare beneficiaries. Risk-adjusted payments incentivized the health plan to prioritize and serve this population effectively.

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Area of Science:

  • Geriatric Medicine
  • Health Services Research
  • Health Policy

Background:

  • The Health Care Financing Administration launched a second-generation Social Health Maintenance Organization (HMO) demonstration in 1996.
  • This model integrated chronic care benefits with a primary care-focused geriatric service model and risk factor screening.
  • Key refinements included risk-adjusted capitation, expanded benefits, low co-payments, and no expenditure caps.

Purpose of the Study:

  • To evaluate the implementation of a geriatric service model within a Social HMO.
  • To assess the integration of primary care, specialty support, and care management for complex cases.
  • To determine the effectiveness of the geriatric approach in reducing illness and disability.

Main Methods:

  • A case study design was employed to examine the Social HMO implementation through Fall 1999.

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  • The study setting was Health Plan of Nevada (HPN), serving Medicare beneficiaries in Las Vegas, Reno, and surrounding areas.
  • Data were collected through administrative reports, charts, and interviews with over 25,000 participants' administrators and clinicians.

    • Main Results:

    • Within 12 months, HPN implemented a screening program to identify high-risk patients and integrated primary care for illness/disability reduction.
    • Geriatric education and consultation programs were established, though full implementation awaited a dedicated geriatrician.
    • The program successfully identified and began addressing the needs of patients at risk for high service costs and disability.

    Conclusions:

    • Health Plan of Nevada's Social HMO program effectively integrates chronic care within an HMO framework.
    • Risk-adjusted reimbursement and Medicare capitation supplements incentivize health plans to prioritize and serve high-expenditure populations.
    • The model demonstrates a viable approach to restructuring health plans for improved management of at-risk populations.