Future of 'Social' HMOs in doubt after nearly 20 years aiding the frail

Barbara Collins once was the epitome of an independent woman. During the 1950s, she was one of just a handful of cross-country female truck drivers plying the country's roads.

These days, Collins needs more than a little help to get by. The 73-year-old widow has asthma, heart disease, a stress fracture in her back and has undergone foot surgery that has left her barely able to walk.

Her physical condition has made it hard for Collins to maintain her independence, but she has been able to avoid entering a nursing home.

Every weekday her Medicare HMO, SCAN Health Plan, sends a home care worker to her Long Beach apartment to help out with house work, food shopping and the like.

The worker "help keeps my house in shape. She does my laundry. If I have to go to Vons she will wheel me over," said Collins. "SCAN has been very good to me."

What kind of Medicare HMO - in an era where even the costs of pharmaceutical benefits have driven large insurers out of the ranks of Medicare managed care - can afford to provide such services?

They are the "social HMOs" and SCAN is one of just four nationwide. Formed as demonstration programs authorized by Congress in 1984, social HMOs are intended to relieve family members of some of the burden of providing such care while delaying entry into nursing homes.

The programs provide all the benefits of regular Medicare HMOs, such as paying the cost of prescription drugs, but they also assume a range of personal and household assistance. To do so, they receive higher reimbursements from the federal Medicare program, based on a formula that takes into account the number of frail elderly they serve.

But while the 50,000-memer Long Beach-based health plan boasts that it has kept thousands out of nursing homes through its services, SCAN is at a crossroads.

Future uncertain

The demonstration program, in California and several other states, has been extended several times since its original authorization, but the most recent extension, as part of the Balanced Budget Act of 1997, requires the Secretary of Health and Human Services to essentially make a decision on the plans" future.

Rep. Steve Horn, R-Long Beach, introduced legislation last month that would make the plans permanent and gradually extend them nationwide, but a report submitted to Congress by the Health and Human Services Department has questioned their cost effectiveness.


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