Social HMOs can ensure senior's health and independence: "it is clear that Medicare needs to be updated, but the question is how. What type of program will meet the needs of the 21st century?" - Medicine & Health

TAKE A MOMENT to think about a situation you or a loved one may be facing now or in the near future. Imagine that you are over 65, on Medicare, and develop a chronic, debilitating disease. Your doctor prescribes a drag to keep the disease under control, but the medication costs $300 a month and does nothing for your symptoms of dizziness, weakness, and severe joint pain. You find it hard to bathe, dress yourself, and prepare your own meals. You cannot drive your car any longer. Now, imagine that you live alone and have no relatives nearby. How do you manage?

Medicare will cover your visits to the doctor, but it provides for none of the other things you desperately need, such as help in paying for the prescriptions, taking a bath and getting dressed, or preparing your meals, and Medicare certainly won't help driving your car. What do you do? How do you maintain your health and your ability to live independently?

Unfortunately for many Americans, this is not a far-fetched scenario. It is what many seniors face today. Countless more will do so as the population ages. Seventy-five million baby boomers will start turning 65 in 2010. Moreover, the Medicare today's seniors and the baby boomers are counting on to help when they get sick is just not designed to cover the full spectrum of their needs.

Medicare was created in 1965, when the world was a different place. Paying primarily for doctor visits and hospital stays was sufficient in those days, because they were the high-cost items. Life expectancy was about 70 years, and people were not living a long time when they had debilitating chronic conditions. There were not as many expensive drugs on the market, and there were often family members nearby to help out when necessary.

You would be hard-pressed to find any health care professional today who would not agree that Medicare is a dinosaur. It was created almost four decades ago and has not kept pace with the changes in society. Medical science and technology have made impressive advances, including drugs and therapies to treat life-threatening diseases, transplants to replace damaged organs, and other medical innovations that allow people to live longer with chronic conditions. These changes have made the acute-care model of Medicare, where everything is based on a "sickness episode" obsolete.

Additionally, Medicare was created in an age of "normal" medical cost inflation. It was not necessary to have controls in place to manage the expense and volume of the services being provided. Since that time, the nation has experienced an unprecedented increase in the cost of medical care. In 1970, health care spending was 7.1% of U.S. gross domestic product. Today, it is 13.4% of GDP.

It is clear that Medicare needs to be updated but the question is how. What type of program will meet the needs of the 21st century? The answer is one that encourages seniors' independence and does so in a cost-effective manner. Some believe that a model for this kind of program exists in what is called a social health maintenance organization (HMO). The comprehensive nature of the model helps to promote both the health and the independence of seniors.

This concept of care is timely and necessary to meet current and future needs, and should be available as an alternative for more Americans. The track record of the social HMO should inspire the design of the new Medicare. A social HMO takes into account medical care and social services, and considers people who have long-term chronic conditions. That is important, because 52% of today's seniors currently have such an ailment.

The Los Angeles Times' Washington, D.C., columnist, Bob Rosenblatt, offered a good description of the benefits members of a social HMO might enjoy: "Imagine an HMO for people on Medicare that throws in some priceless extra services designed to help keep frail older Americans out of nursing homes. ... Our imaginary HMO does a lot more outside the purely medical realm. This HMO might send a health care worker to a woman's home several times a week to help her bathe. Or it might dispatch a household aide to clean her home or prepare a few days' worth of meats. Another time, this health plan might provide an otherwise homebound elderly man with a day-care center for an afternoon, where he can socialize and get a break from the usual routine."

The idea of updating Medicare to meet the needs of older people originated in the early 1980s. A group of collaborative researchers from Brandeis University and the Health Care Financing Administration designed a plan, later to be called the social HMO, that added certain non-Medicare-covered social services to the existing Medicare health maintenance organization. Social services that were added included care management and community-based services. Think of these services as assisted living at home.

The researchers' goal was to demonstrate that providing these services would help seniors avoid unnecessary nursing home placement and do so in a manner that remained budget-neutral when compared with fee-for-service Medicare. The model pools Medicare and Medicaid dollars and appropriate financial participation from the individual, in the form of copayments and, sometimes, monthly premiums. In 1985, following up on this concept, the Health Care Financing Administration designated four sites across the country as demonstration projects to test how the social HMO model would work.