Care Management in the S/HMO Demonstrations

Roberto Vuittonet

I believe that despite the potential benefits, the cost and challenges of Social Health Maintenance Organization (S/HMO) far outweigh the benefits. On the basis of operational and administrative costs, it is more efficient to make chronic care benefits to a HMO as opposed to adding HMO component t community care providers (Saucier, Burwell & Halperin, (2013).  There are also more existing options available in the market that serve the same needs. It is also observed that up to date, the difference between S/HMO and existing Medicare HMOS.  

Up to date there is no existing data to show any benefits directly attributed to S/HMO case management. Existing data shows that Medicare care management when targeted at a specific condition will have more promise. This is because focusing activities on specific activities creates specialized outcomes.

There are some benefits from S/HMOS. First, there are additional benefits such as chronic care management, prescription drugs benefits, personal care management, adult day care, respite care, medical transportation, dental and hearing aids. Enrollees also have access to legal aid, housing and other social security benefits. However, these benefits come at a cost. The Enrollees therefore have to choose the benefits over cost. The current problem facing healthcare in the United States is rising cost. Most of the Medicare beneficiaries are seeking cheaper alternatives for healthcare. Although the enrollees in S/HMOs can maximize their benefits, there is little evidence of any cost savings. It therefore means that S/HMOs have little considerable benefits over existing alternatives in the market.

References

Saucier, P., Burwell, B., & Halperin, A. (2013). Consumer choices and continuity of care in managed long-term services and supports: Emerging practices and lessons. AARP Public Policy Institute. Retrieved March, 17, 2015.

Discussion #3

Bryan Cerritos

The Social health maintenance organization (S/HMO) demonstration was initiated in 1980 by the Health Care Financing Administration (HCFA), in cooperation with the Health Policy Center of Brandeis University, with the intention of providing acute and chronic care services under a prepaid plan for the elderly population (Yordi, 1988). These service would be compensated on a capitated basis, along with premiums, and even by Medicaid (Yordi, 1988). Beneficiaries that meet their state’s nursing-home-certifiable adjusted criteria upon enrollment receive an adjusted Medicare capitated rate (Yordi, 1988). All enrollees are eligible for basic Medicare benefits, but those with assessed as nursing home certifiable or “at risk” of nursing home placement are eligible for chronic care benefits (Yordi, 1988).

Any healthcare program that is created for the aim of specifically serving the needs of a target population is highly relevant and should be supported. This is especially the case for a program designed to serve the needs of a high demand consumer group such as the often neglected chronically ill elderly population. Demonstrations like the S/HMO and other similar programs aid the viability of the healthcare industry in various ways. First, they direct attention and resources at a population base that traditionally requires much more intensive and specialized healthcare then normal. This population base is often unable to provide for themselves, let alone ensure they receive proper medical care. The S/HMO addresses this demographic’s uniques needs, and simultaneously alleviates the workload placed on the general healthcare market by creating a special interest healthcare initiative. The care managed approach also ensures greater effectiveness and long term viability through prevention and proper follow ups.

Reference

Yordi C. L. (1988). Case management in the social health maintenance organization demonstrations. Health care financing review, Spec No(Suppl), 83–88.