Background
Over the past decade, managed care has emerged as the dominant market force in the reshaping of our nation's health care system. California has been at the forefront of the move to managed care. In fact, most commercially insured working individuals in the state are now enrolled in some type of managed care system. In addition, Californians represent well over one-third of all U.S. Medicare beneficiaries enrolled in Health Maintenance Organizations (HMOs). It is expected this percentage of elder Californians served by such care systems will continue to increase.
The promise of managed care for frail and at-risk elders includes enhanced coordination and integration of care across providers, locations and time; increased emphasis on prevention and community-based care; and greater flexibility in the types of services, providers and settings available for care. The enrollment of elders in Medicare HMOs has increased dramatically in California, due mostly to the appeal of lower out-of-pocket costs, decreased paperwork and added benefits, such as prescription drug and vision coverage. However, much still remains to be learned regarding how best to structure systems of care for frail and at-risk elders. Questions include which services are most beneficial to which elders; the optimal times, providers, payers and places for these services; and most importantly, how to ensure quality care.
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Program Description
In November 1997, the California HealthCare Foundation allocated $15 million over five years for its Program for Elders in Managed Care. The Program was intended to foster comprehensive, systematic improvements in service delivery for Californians in Medicare managed care plans. Californians represent one-third of total U.S. Medicare HMO enrollees. This large and growing population of elders experiencing, or at risk of, functional decline poses substantial challenges for health plans and providers. While managed care organizations (e.g., health plans, medical groups, integrated health systems) have been relatively proficient in caring for healthier elders, only a few have developed strategies for coordinating and delivering a full range of health and supportive services to sick or at-risk elders. Even fewer have developed strategies for providing culturally appropriate services to California's rapidly growing racially and ethnically diverse elder population. By providing small grants for planning, and larger grants for implementation and evaluation, the California HealthCare Foundation sought to stimulate the development of better-organized systems of care for California elders who have serious and persistent health care needs and who are enrolled in managed care. This effort was based on the premise that enhanced services, closer monitoring, evidence-based practice, and improved coordination of care will lead to better patient outcomes and increased patient and provider satisfaction. Through careful evaluations, the California HealthCare Foundation hoped to show these better outcomes clearly, spurring grantee organizations to expand their innovations and motivating others to adopt these improvements in systems of care. California has a wealth of community-based organizations, academic research centers, and managed care organizations, each with substantial and different areas of expertise. This initiative is intended to help meld and apply this collective clinical, research, management and financial expertise towards improved care for frail and at-risk elders. In addition to awarding grants for planning, implementation and evaluation through a Request for Proposals process, the Program will commission work in a number of related areas that supports the goals of the program and complements the demonstration projects.
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Program Structure
Through grants for planning, implementation and evaluation, the Foundation supported innovations in care for elders that:
- enhanced the autonomy, dignity and independence of elders in managed care through increased information, choice, and capacity for consumer direction;
- involved partnerships among community-based service agencies, medical groups, integrated health systems, health plans, researchers, and/or others working together to find better ways to provide and coordinate services;
- incorporated a broad view of health (including psychosocial issues, living arrangements and social support) beyond specific medical conditions; and
- were comprehensive in scope and addressed the need for a full continuum of care.
Planning Grants
Eight one-year planning grants were made for up to $75,000 each to support activities related to designing new or improved systems of care, such as needs assessments, feasibility studies, and partnership development.
Demonstration Grants
Ten three-year grants were made for up to $1 million each to support the implementation of new or reorganized systems of care, and the evaluation of the effectiveness and costs of these systems.
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