Social Health Maintenance Organization Research Articles

PCN316 TREATMENT PATTERNS OF ADVANCED SOFT-TISSUE SARCOMA IN ARGENTINA

To describe the treatment patterns of patients with advanced soft-tissue sarcomas who received chemotherapy or radiotherapy in Argentina. Patients with advanced soft-tissue sarcoma (locally advanced, inoperable, or metastatic disease) who received chemotherapy or radiotherapy from 2013-2018 were selected from the Instituto de Especialidades Médicas S.A. (IEMSA) clinical database, which collects the information of several insurance providers (Social Security System and Health Maintenance Organizations). Cases with osteosarcoma, Kaposi’s Sarcoma and gastrointestinal stromal tumors were excluded. A total of 99 patients were analysed. There was a high variability in histological type, with leiomyosarcoma (N=17; 17%), pleomorphic sarcoma (N=12; 12%), liposarcoma (N=10; 10%), and rhabdomyosarcoma (N=10; 10%) being the most frequent. The most frequent locations were leg (33%), abdomen (16%), and arm (14%). At the time of diagnosis, 46% of the cases were localized, 26% were loco-regionally advanced and 27% were metastatic. Of the 99 patients, 50.5% received adjuvant/neoadjuvant therapy, and of them, 50% received only chemotherapy, 30% received only adjuvant/neoadjuvant radiotherapy, and 20% received both therapies. There were 86 patients who received first-line therapy for metastatic disease. Seventy-nine percent of them received chemotherapy. The most frequent chemotherapy was doxorubicin-ifosfamide-mesna (N=22; 32%), and docetaxel-gemcitabine (N=6, 9%), and epirubicin-ifosfamide-mesna (N=3; 4%). There was a high variability in the rest of the treatments. During the first-line therapy, twenty-one patients (24%) had surgery, and fifteen patients (17%) received radiotherapy. Only one patient had a complete response after first-line chemotherapy. Forty-five patients received second-line therapy, 93% of whom received chemotherapy. Again, the most frequent treatments were doxorubicin-ifosfamide-mesna (N=13; 31%) and docetaxel-gemcitabine (N=9; 21%). Two patients experienced a complete response with second-line therapy. There is a high variability in the treatment of advanced soft-tissue sarcomas in Argentina. Response to current chemotherapy treatments is very poor. There is a large need for more effective treatments.

Conversion Diversion: Participation in a Social HMO Reduces the Likelihood of Converting From Short-Stay to Long-Stay Nursing Facility Placement

To determine the effect of a Social Health Maintenance Organization (S/HMO) on diverting older adults admitted into a nursing facility from converting to long-stay placement. Members of the SCAN S/HMO and those in Medicare Fee-For-Service were compared on successful discharge to the community after being admitted to nursing facilities between January 1, 2001, and December 31, 2003. Skilled nursing facilities in 4 counties in Southern California (Los Angeles, Orange, San Bernardino, Riverside). Data (N = 4635) were extracted from Minimum Data Set (MDS) 2.0 records for nursing facility residents in the S/HMO or the Medicare Fee-for-Service 5% sample who were aged 65 and older with an episode of care greater than 14 days. Predisposing, enabling, and need measures were used to predict successful discharge to the community within 90 days. After controlling for selected sociodemographics, comorbidities, behavioral issues, mental health conditions, and other risk factors, being enrolled in the S/HMO increased the likelihood of successful discharge by 26%. With systemic increases in short-stay patients, research on diversion must look past the avoidance of unnecessary entry to nursing facilities, to the successful transition of short-stay residents to the community. As described in this study, the S/HMO model is an important but largely unaddressed method of avoiding the conversion to long-stay.

Experiments in Coordinated Elder Care

Experiments in Coordinated Elder Care

Meeting the Needs of Disabled Older Persons: Can the Fragments Be Pieced Together?

ONE of the first things we learn in geriatrics is that, as people get older, their health needs extend beyond the purely medical. Actually, this is the case for other populations (e.g., very young children and all patients with devastating illnesses). The common issue is that these patients are unable to take their illnesses in stride and go on with the rest of their lives. Rather, health becomes the overriding force in their lives, and resources must be mounted to compensate for the deficits incurred by disease and debility. In geriatrics, the onset of functional impairment (particularly in activities of daily living) marks the transition of the role of health from bit player to lead actor. Certainly, older persons have larger disease burdens, but there is much more contributing to the impact of poor health including the loss of social support, financial limitations, and societal barriers such as the lack of geriatric-friendly housing and communities. When all of these are considered, it becomes obvious that care for the functionally impaired, community-dwelling elderly patient requires more than a physician or a health care system can provide. In the United States, we are celebrating the 40th anniversary of the Medicare program, a landmark piece of legislation enacted by the Johnson administration. As conceived, this program intended to relieve elderly Americans of the worry of becoming health care paupers once they retired and lost their commercial health insurance. The program has been enormously successful, though costly. Older persons have excellent access to health care and receive plenty of it. Yet, in its design and implementation, there have been inherent flaws in Medicare that fail to recognize the basic principle that medical care alone is insufficient. This oversight is understandable. The fee-for-service Medicare system was largely based on the Blue Cross and Blue Shield insurance plans, which were medically oriented and rewarded the volume of medical services provided, particularly procedures. In addition, life expectancy in the 1960s was substantially shorter (1) than today, and the numbers of older persons, those who were frail, was relatively small. Now, halfway through the first decade of the millennium, we are anticipating 75 million baby boomers who will begin to reach Medicare eligibility based on age in 2011. Moreover, the most rapidly growing age group in the United States is the 85 years and older population. With advancing age, functional impairment rises. For example, 20% of persons 65–74 years of age have difficulty with activities of daily living, whereas 53% of those 85 years and older have difficulty with these tasks (2). Providing assistance with these tasks largely remains outside the benefits package provided by Medicare. These demographic data underscore the pressing need to reconsider how health care is conceptualized for older persons. In the United States, several attempts have been initiated to blend medical and social services to meet the comprehensive medical and social needs of frail older persons. Among the most prominent has been the Program for Allinclusive Care of the Elderly (PACE) and the social health maintenance organizations (S/HMO). Both have had some successes (3,4) but they also have limitations (e.g., participants’ inability to retain their own physicians, high premiums for those who are not eligible for Medicaid, modest interest among insurers) and have not become widely available. In this issue of the Journal, Beland and colleagues report the results of a large, carefully conducted trial of an integrated (blending health and social services) health care delivery system (SIPA; French acronym for System of Integrated Care for Older Persons) launched in Canada (5). Some notable features of the SIPA system include assessment followed by evidence-based interdisciplinary protocols for the conditions that frail older people commonly experience (e.g., falls, heart failure, depression, dementia, medications). SIPA mobilized medical and social services, including case management, to keep patients out of the hospital. Another positive aspect of the program is that the patient’s family physician continues to provide the medical care. Moreover, the program provided financial incentives for physician participation ($400 annually, the equivalent of $33 [Canadian] per member per month) to compensate for time spent communicating with the multidisciplinary team. Although the results are not as positive as one might have hoped, the authors state that the findings of reducing more expensive care (acute care) while increasing less expensive care (e.g., home health) met the study’s hypotheses. Obviously, the model of care would have been more compelling if total costs were reduced. It is hard to persuade insurers and delivery systems to adopt change in the absence of a bottom line benefit on health or costs. Nevertheless, costs are a fickle outcome because of health care delivery idiosyncrasies and outliers, which can substantially influence

Utilization and costs of home-based and community-based care within a social HMO: trends over an 18-year period

Our objective was to describe the utilization and costs of services from 1985 to 2002 of a Social Health Maintenance Organization (SHMO) demonstration project providing a benefit for home-based and community-based as well as short-term institutional (HCB) care at Kaiser Permanente Northwest (KPNW), serving the Portland, Oregon area. The HCB care benefit was offered by KPNW as a supplement to Medicare's acute care medical benefits, which KPNW provides in an HMO model. KPNW receives a monthly per capita payment from Medicare to provide medical benefits, and Medicare beneficiaries who choose to join pay a supplemental premium that covers prescription drugs, HCB care benefits, and other services. A HCB care benefit of up to 12,000 dollars per year in services was available to SHMO members meeting requirement for nursing home certification (NHC). We used aggregate data to track temporal changes in the period 1985 to 2002 on member eligibility, enrollment in HCB care plans, age, service utilization and co-payments. Trends in the overall costs and financing of the HCB care benefit were extracted from quarterly reports, management data, and finance data. During the time period, 14,815 members enrolled in the SHMO and membership averaged 4,531. The proportion of SHMO members aged 85 or older grew from 12 to 25%; proportion meeting requirements for NHC rose from 4 to 27%; and proportion with HCB care plans rose from 4 to 18%. Costs for the HCB care benefit rose from 21 dollars per SHMO member per month in 1985 to 95 dollars in 2002. The HCB care costs were equivalent to 12% to 16% of Medicare reimbursement. The HCB program costs were covered by member premiums (which rose from 49 dollars to 180 dollars) and co-payments from members with care plans. Over the 18-year period, spending shifted from nursing homes to a range of community services, e.g. personal care, homemaking, member reimbursement, lifeline, equipment, transportation, shift care, home nursing, adult day care, respite care, and dentures. Rising costs per month per SHMO member reflected increasing HCB eligibility rather than costs per member with HCB care, which actually fell from 6,164 dollars in 1989 to 4,328 dollars in 2002. Care management accounted for about one-quarter of community care costs since 1992. The Kaiser Permanente Northwest SHMO served an increasingly aged and disabled membership by reducing costs per HCB member care plan and shifting utilization to a broad range of community care services. Supported by a disability-based Medicare payment formula and by SHMO beneficiaries willing to pay increasing premiums, KPNW has been able to offer comprehensive community care. The model could be replicated by other HMOs with the support of favorable federal policies.

Geriatric Versus Non-Geriatric Approach of Care to Moderate P ra Risk Senior Population

A total of 432 members of Senior Dimensions, a second-generation social health maintenance organization, residing in northern Nevada were identified as moderate risk by P(ra) screening criteria for the time period of July 1, 2002, through June 30, 2003. Of these members, 166 were impaneled to a practice that only provides care for seniors (age 65 years or older), Geriatric Care of Nevada (GCN), and 266 members were impaneled to multiple primary care providers with standard community-based practices (non-GCN). An annualized cost comparison per unit of service provided as derived from the adjusted use data showed an average savings of $760.00 per member per year for the GCN over the non-GCN population. These savings have occurred apart from the provider fee reimbursement. This represents a potential savings of more than $760,000.00 per year per 1000 moderate P(ra) risk members within a Medicare managed care program.

Chronic Care Initiatives for the Elderly: Can They Bridge the Gerontology-Medicine Gap?

The authors describe initiatives designed to meet the chronic health needs of the elderly. These programs include demonstration programs such as Program of All-Inclusive Care for Elderly, Social Health Maintenance Organization, and state programs for Medicare-Medicaid-eligible elders that focus on integrating medical care with home and community-based services, disease- or disability-focused care management/coordination initiatives, and recent population-based disease management programs focused on improving adherence to evidence-based protocols, self-care management, and the use of innovative practices such as group visits to improve health outcomes. These initiatives have the potential to improve outcomes and reduce costs, but also highlight tensions between medical model disease management and functionally oriented home and community service programs. The authors suggest that optimal chronic care for elders would require the integration of advances in medically oriented disease management with the best of home and community-based service programs. Medicare policy should promote such integration.

Community-based care and risk of nursing home placement.

To test the substitution hypothesis, that community-based care reduces the probability of institutional placement for at-risk elderly. The closure of the Social Health Maintenance Organization (Social HMO) at HealthPartners (HP) in Minnesota in 1994 and the continuation of the Social HMO at Kaiser Permanente Northwest (KPNW) in Oregon/Washington comprised a "natural experiment." Using multinomial logistic regression analyses, we followed cohorts of Social HMO enrollees for up to 5 years, 1995 to 1999. To adjust for site effects and secular trends, we also followed age- and gender-matched Medicare-Tax Equity and Fiscal Responsibility Act (TEFRA) cohorts, enrolled in the same HMOs but not in the Social HMOs. All enrollees in the Social HMO for at least 4 months in 1993 and an age-gender matched sample of Medicare-TEFRA enrollees. To be included, individuals had to be alive and have a period out of an institution after January 1, 1995 (total n = 18,143). The primary data sources were the electronic databases at HP and KPNW. The main outcomes were long-term nursing home placement (90+ days) or mortality. Covariates were age, gender, a comorbidity index, and geographic site effect. Adjusting for variations in the 2 sites, we found no difference in probability of mortality between the 2 cohorts, but approximately a 40% increase in long-term institutional placement associated with the termination of the Social HMO at HealthPartners (odds ratio, 1.43; 95% confidence interval, 1.15-1.79). The Social HMO appears to help at-risk elderly postpone long-term nursing home placement.

Age Concerns

Summary Age Concerns is a proprietary care management firm serving the elderly. Established in 1982, the firm has prospered by employing an integrated model of care whereby the caregivers are employees of Age Concerns. In addition, the firm's ability to keep the elderly at home, out of institutional care, has resonated with consumers. Various features of Age Concernsorganizational format, characteristics of consumers, and economic considerationsare described. In 2001, Age Concerns was acquired by the Senior Care Action Network, a social health maintenance organization. In an increasingly commercial environment in which the elderly are a burgeoning market, Age Concerns may be a prototype of future elder-care service delivery.

Challenges and accomplishments of the second-generation social health maintenance organization.

This study traces the implementation of the second-generation Social HMO demonstration program within the Health Plan of Nevada among more than 35,000 Las Vegas members. This case study uses health plan reports, claims data, and administrator and clinician interviews covering the years 1999-2001. Care coordination, geriatric services, communications, and support infrastructure development has been extensive. Implementation has occurred at different rates among staff model and network practice physicians. Hospital days and discharges were fewer among clinic than network participants; physician and emergency room visits were more frequent, as were day care, respite care, and home help. Integrating medical and social care is difficult. Despite great efforts, it took several years before key benefits could be adequately developed and linkages created. Evaluations that target start-up rather than steady-state operation may not capture these accomplishments. Further, federal government efforts to encourage experimentation and innovation in care for aged and disabled individuals may require programs other than time-limited demonstrations.

Geriatric depression, antidepressant treatment, and healthcare utilization in a health maintenance organization.

To assess the separate effects of depressive symptoms and antidepressant treatment on healthcare utilization and cost. Social Health Maintenance Organization (HMO) at HealthPartners in Minnesota. Geriatric Social HMO enrollees were screened for depressive symptoms using the 30-item Geriatric Depression Scale. A stratified sample was created, composed of geriatric enrollees with depressive symptoms, with antidepressant prescriptions, or with neither (n = 516). Regression analyses were conducted with separate equations for utilization and charge outcome variables, both outpatient and inpatient (log-transformed). The Charlson Comorbidity Index, age, and gender served as covariates. Depressive symptoms were identified through the Diagnostic Interview Schedule. Antidepressant treatment was determined from the HMO pharmacy database. Having depressive symptoms was associated with a 19 increase in the number of outpatient encounters and a 30 increase in total outpatient charges. Antidepressant treatment was associated with a 32 increase in total outpatient charges but was not significantly associated with number of outpatient encounters. Depressive symptoms and antidepressant therapy were not significantly associated with inpatient utilization or charges. This study found that patients with depressive symptoms generated more outpatient health care and higher charges but not necessarily more inpatient care. Our findings suggest that programs targeted to geriatric patients whose depression is comorbid with other chronic medical conditions might be cost-effective and particularly appropriate for geriatric care.

Social health maintenance organizations part II

Social health maintenance organizations part II

Social health maintenance organizations part I

Social health maintenance organizations part I

Predictors of Use of Chronic Care Services by Impaired Members in the Social Health Maintenance Organization Demonstration

Use of chronic care services by 1,868 impaired members of the first Social Health Maintenance Organization (SHMO) demonstration was examined using a modified Andersen behavioral model. Services studied included skilled and intermediate nursing facilities, adult day care, home health, and personal care. A two-part regression analysis was performed to identify significant predictors of any use and amount of use. Individual needs such as activities of daily living were important predictors of service use even for impaired SHMO members. Variance predicted by enabling variables, especially site, was also particularly significant. This emphasizes the importance of including health plan and market factors in future modeling of service use. Other important findings were that low-income members were more likely to be placed in nursing homes and only about 65% of impaired members received any formal home care.

The changing elderly population and future health care needs.

The impending growth of the elderly population requires both fiscal and substantive changes in Medicare and Medicaid that are responsive to cost issues and to changing patterns of need. More emphasis is required on chronic disease management, on meaningful integration between acute and long-term care services, and on improved coordination between Medicare and Medicaid initiatives. This paper reviews various trends, including the growth in managed-care approaches, experience with social health maintenance organizations and Program of All-Inclusive Care for the Elderly demonstrations, and the need for a coherent long-term care policy. Such policies, however, transcend health care and require a broad range of community initiatives.

The Closing of a Social HMO

ABSTRACT A social health maintenance organization (SHMO) integrates acute and long-term care and provides an extended-care benefit for elderly who are at risk of institutionalization. This article reports findings from a case study of the termination of the Group Health SHMO in Minnesota. Interviews were conducted with social workers and at-risk elderly who had been receiving long-term care through the SHMO. The case study examines the post-SHMO transition and the process of replacing SHMO care coordination and long-term care services. Most of the elderly and their caregivers indicated they were “losing ground” - that is, they were paying more or getting less care. Some were paying more for less care. Because they tended to switch to private-pay arrangements and to rely more on informal care, it appears that their care system became much less stable after the closing of the SHMO.

Benzodiazepine exposure and functional status in older people.

To determine the association between benzodiazepine exposure and functional status in older patients. A nonexperimental, observational study design. Kaiser Permanente, Northwest Division, a health maintenance organization (HMO) providing prepaid, comprehensive inpatient and outpatient care for more than 410,000 persons. Patients were the 4192 Social HMO Project members 65 years of age and older, enrolled for 1 full year, who returned their annual health status survey during 1990. Functional status was measured using self-reported activities of daily living and instrumental activities of daily living. Predictor variables were self-reported medical conditions and benzodiazepine exposure during the previous 12 months. Age, gender, and living status were associated with functional status. Severe memory loss, stroke, Parkinson's disease, circulation problems, lung problems, hip fracture, urinary problems, arthritis, heart trouble, diabetes, stomach/bowel problems, and cancer were associated independently with functional status. Persons exposed to a benzodiazepine scored lower on the functional status measure. Benzodiazepine exposure added significantly to the prediction of functional status after controlling for patients' socio-demographic characteristics and medical conditions. Age and medical conditions were the most significant predictors of functional status. Benzodiazepine exposure was associated with functional status to the same extent as several chronic medical conditions. When prescribing benzodiazepines for older people, caution should be taken to minimize the possibility of iatrogenic-functional limitations.

Development of an End-Stage Renal DiseaseManaged Care Demonstration

At present, end-stage renal disease (ESRD) beneficiaries cannot enroll in health maintenance organizations (HMOs) or social health maintenance organizations (SHMOs), but HMO members who develop ESRD may remain enrolled, and the Health Care Financing Administration (HCFA) pays the HMO a state-specific, but otherwise unadjusted, capitation rate that is 95% of fee-for-service (FFS) costs. Thus, more than 6,000 ESRD beneficiaries were enrolled in HMOs in 1993, when Congress mandated an ESRD SHMO demonstration in which not only Medicare-covered services, but extra benefits were to be provided to Medicare beneficiaries, with the SHMO receiving a capitation rate based on 100% of FFS costs. The demonstration will test (1) the feasibility of year-round open enrollment of ESRD beneficiaries in HMOs; (2) a capitation system based on treatment status--dialysis, transplant, or functioning graft--and adjusted for age and whether diabetes was the cause of renal failure; (3) the effect of the additional benefits; and (4) whether managed care can improve ESRD quality outcomes. HCFA made demonstration awards in September 1996 to Kaiser-Permanente in Southern California; Health Options in Southern Florida; and Phoenix Healthcare in Central Tennessee. The sites are expected to have 1 year of planning and development before beginning the congressionally mandated 3 years of service delivery. There will be an independent evaluation.

S/HMOs, the second generation: building on the experience of the first Social Health Maintenance Organization demonstrations.

S/HMOs, the second generation: building on the experience of the first Social Health Maintenance Organization demonstrations.

Medical Care Utilization Among Older HMO Members With and Without Hypertension

To compare hospital utilization, health status, and sociodemographic characteristics of older persons with and without hypertension and to examine the nature of the association of hypertension with medical care utilization. A retrospective, nonexperimental study. A large health maintenance organization (HMO), located in the Portland, Oregon and Vancouver, Washington areas, that provides comprehensive, prepaid benefits to its members. Approximately 4200 older (> or = 65 years) members enrolled in the Social HMO Demonstration Project. The dependent variables were (1) whether a member was hospitalized (0 = no; 1 = yes) and (2) the number of hospitalizations during the 12-month period before the return of the Health Status Form, a mail questionnaire. The predictor variables were high blood pressure and other medical conditions, health status, and sociodemographic characteristics. Patients classified as hypertensive were those who self-reported high blood pressure and who received two or more dispensings for antihypertensive medications. Older hypertensives were more likely than older nonhypertensives to have been hospitalized (odds ratio (OR) = 1.14 (95% CI 1.01, 1.27)), self-report their health as only good or fair (P < .001), self-report IADL functional limitations (P < .001), and to be younger than nonhypertensives (P < .001). Utilization differences were similar after controlling for patients' age and gender. Factors independently associated with an increased likelihood of hospitalization were male gender (OR = 1.14 (1.00,1.31)), age (OR = 1.35 (1.00,1.81)), poor (OR = 1.32 (1.02,1.72)) or fair (OR = 1.20 (1.01,1.44)) self-rated health status, functional limitations in activities of daily living (OR = 1.74 (1.48,2.03), and self-reported heart trouble (OR = 1.50 (1.34,1.68)), stroke (OR = 1.37 (1.15,1.64)), or cancer (OR = 2.89 (1.72,4.84)). Factors independently associated with a decreased likelihood of hospitalization were excellent self-reported health (OR = 0.65 (0.47,0.90)), no physical impairments (OR = 0.59 (0.48,0.72)), and no circulation problems (OR = 0.85 (0.74,0.98)). Older hypertensive patients had poorer self-reported health, more functional limitations, used more hospital services, and were not as old as nonhypertensive older patients. To the extent that general health is improved by treatment of hypertension, appropriate treatment of high blood pressure may not only improve health, it may also reduce medical care utilization. Our findings offer further support for hypertension prevention, detection, and treatment programs designed to reduce or minimize hypertension's later medical complications and to reduce future utilization.