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Challenges and Accomplishments of the Second-Generation Social Health Maintenance Organization

^a Department of Social and Behavioral Sciences, University of California, San Francisco
^b University of Minnesota School of Public Health, Minneapolis

Correspondence: Robert Newcomer, PhD, Department of Social & Behavioral Sciences, University of California, 3333 California Street, Suite 455, San Francisco, CA 94118. E-mail [email protected]

Decision Editor: Laurence G. Branch, PhD

Purpose: 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. Design and Methods: This case study uses health plan reports, claims data, and administrator and clinician interviews covering the years 1999–2001. Results: 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. Implications: 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.

Key Words: Managed care • Aged • Medicare • Care management

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