Implementing the second generation social health maintenance organization

BACKGROUND: In 1996 the Health Care Financing Administration implemented a second generation of the Social HMO demonstration. This model retained the chronic care benefits of the original Social HMOs while attempting to devel op a geriatric service model integrated into primary care and a screening a nd assessment process focused directly on healthcare risk factors. Other re finements included risk-adjusted capitation payment, broadened eligibility for expanded care benefits, low co-payments for these benefits, and no caps on the expanded care benefits expenditures. OBJECTIVES: The geriatric approach is designed to facilitate integration am ong providers and levels of care. This includes timely application of prima ry care monitoring and treatment to reduce illness and disability as well a s a geriatric education and consultation program to provide specialty suppo rt for complex cases. Care management is designed for those requiring home- based care, those discharged from hospitals or nursing homes, and those hav ing difficulty with treatment regimens. DESIGN: A case study of the Social HMO implementation through the Fall of 1 999. SETTING: Health Plan of Nevada (HPN), with locations in Las Vegas, Reno, an d surrounding areas. PARTICIPANTS: More than 25,000 Medicare beneficiaries participated during t he study period. MEASUREMENTS: Administrative reports, charts, and interviews with administr ators and clinicians. RESULTS: Within 12 months of operation under this authority, HPN succeeded in putting in place most of the components of the planned geriatric approac h: a screening program to identify patients "at risk" for high service cost s and disability and timely application of primary care treatment to reduce illness and disability. Geriatric education and a consultation program for complex cases were available, but full implementation was delayed until th e plan was able to hire a full time geriatrician. CONCLUSIONS: Health Plan of Nevada's Social HMO program reflects current pe rspectives on how to integrate chronic care into an HMO. The accomplishment s affirm that the provision of risk-adjusted reimbursement, along with the 5% supplement to the normal Medicare capitation payment, are sufficient inc entives for a health plan to restructure itself so that it places a priorit y on retaining and serving populations at risk for high expenditures.