December 2003

Grant Results

National Program

Chronic Care Initiatives in HMOs


From 1996 to 2002, researchers at the University of Minnesota Medical School compared the effects on patients and a health plan of using a "care advisor" who coordinated services for senior members of a health plan to those of the plan's regular "gatekeeper" model.

The project was part of the Robert Wood Johnson Foundation (RWJF) Chronic Care Initiatives in HMOs national program.

Key Findings

  • The care advisory group had slightly lower total costs than the regular "gatekeeper" group, primarily due to fewer physician visits.
  • Satisfaction scores were significantly higher in the care advisory group than in the regular "gatekeeper" group.

RWJF supported this project through a grant of $530,371.

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Through its SeniorCare Options program, Minneapolis-based Medica Health Plans, an independent practice association HMO of Allina Health System, allowed senior members open access to 6,000 primary and specialty physicians. (An independent practice association is an HMO model in which the HMO contracts with a physician organization that in turn contracts with individual physicians.)

Open access is a departure from most Medicare managed care programs, which usually employ a care manager (or "gatekeeper"), often a primary care physician, who authorizes or denies services to members.

Medica's care advisory model assigned a "care advisor" to each new member of SeniorCare Options upon enrollment, regardless of health status. The care advisor was either a registered nurse or social worker who managed and coordinated care for moderate and high-risk members or acted as a central resource or liaison for low-risk members.

Upon enrollment, each new SeniorCare Options member received a welcome call from an assigned care advisor who explained the member's coverage and the services offered. New members also received a brief health status screening questionnaire to determine whether the member was at low, moderate or high risk for health problems.

Medica staff expected that a special relationship and sense of familiarity would develop between senior members and care advisors before a need for services arose. The staff anticipated that when senior members developed health problems they would feel comfortable informing care advisors, relying on the advisor's guidance, and presenting themselves early for care in the most appropriate setting. Medica staff also believed that early identification of patients who were at high risk of adverse health outcomes — through use of care advisors — could reduce costs by avoiding incidents that lead to hospitalization.

Follow-up with members depended on their risk level as determined by the initial screening questionnaire:

  • Low-risk members received information in the mail after the welcome call, including referrals to health-promotion activities and a self-care management pamphlet.
  • Moderate-risk members received a more detailed questionnaire that Medica mailed to them, along with a phoned health assessment, which included a mental status screen. These members also received a home visit if the care advisor, after consulting with other team members, determined that one was necessary.
  • High-risk members received a call from a care advisor who arranged a home visit for a more detailed health status assessment. The care team and the plan's geriatric medical director held meetings to discuss all high-risk members. High-risk members received ongoing monitoring by care advisors for at least one year.

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Under this project funded by RWJF as part of its national program Chronic Care Initiatives in HMOs, researchers at the University of Minnesota Medical School were to compare Medica's care advisory program with the plan's traditional gatekeeper programs, measuring data on enrollee's health status, satisfaction with care, utilization of health services and health care expenditures.

The research plan originally intended to enroll subjects concurrently in the care advisory and gatekeeper programs, gather baseline data, and then re-collect data at 12 and 24 months for each group. Researchers also planned to evaluate the care advisory program qualitatively through focus groups.

However, the project ran into a significant obstacle in mid-1997 when Medica announced it would terminate its care advisory program midway through the grant period, in January 1998. After consultation with RWJF's Chronic Care Initiatives in HMOs National Program Office, researchers revised the research plan to collect baseline and outcome data (at 14 and 20 months) on just the care advisory subjects already enrolled in the program. They then collected health status, cost and satisfaction data on a non-concurrent gatekeeper control group in August and September 1997 and used information already collected on these subjects as baseline data.

Out of 501 advisory care subjects and 1,599 control group subjects who had data collected at baseline, researchers were able to match 323 experimental/control pairs on the basis of baseline gender, age and Pra risk scores (which measure risks for hospitalizations and other medical needs). The researchers obtained the cost data from Medica claims records.

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The principal investigator reported the following findings to RWJF in 2002.

  • When controlling for slight differences at baseline (in self-rated health, caregiver availability and education level), the care advisory group had slightly lower total costs than the control group at follow-up, primarily due to fewer physician visits.
  • Satisfaction scores were significantly higher in the care advisory group than in the control group, particularly for items dealing with general satisfaction and accessibility and convenience of medical care.

According to the principal investigator, the slightly lower costs observed for the care advisory subjects suggest that use of care advisors can curb expenditures in an open-access plan. However, he also noted that the higher satisfaction recorded among the care advisory patients could reflect the effect of being interviewed, not the effect of the care advisor program on them.


Researchers did a poster presentation about project results at the annual meeting of the American Geriatrics Society in May 2001 in Chicago. An abstract entitled "Effects of a Care Management Program on Costs and Satisfaction in an Open-Access Health Plan" appeared in the Journal of the American Geriatrics Society. An article about the project findings is in process. See the Bibliography for details.

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  1. Investigators working with managed care organizations should identify a "go to" person at the company who would be responsible for all communication between the company and project investigators. In this project, investigators had to deal with multiple contacts, which seemed to change every few months. With each new contact, investigators felt they were starting anew in their relationship with the organization. (Project Director)
  2. Investigators should be prepared, when studying health plans, to study a "moving target." Research protocols need to be flexible enough to accommodate likely and unforeseen changes in the health plan's operations. (Project Director)
  3. Health plans are extremely sensitive to the direct gathering of data from enrollees. An investigator should be aware of this and take extra pains to work with health plans in designing and implementing acceptable data-collection instruments. (Project Director)

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Evaluation of Using Care Advisors for Chronically Ill Older HMO Enrollees


University of Minnesota Medical School (Minneapolis,  MN)

  • Amount: $ 530,371
    Dates: February 1996 to January 2000
    ID#:  028824


Project Director: James T. Pacala, M.D., M.S.
(612) 625-0954

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(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)


Pacala JT and Boult C. "Effects of a Care Management Program on Costs and Satisfaction in an Open-Access Health Plan" (abstract). Journal of the American Geriatrics Society, 49: S148–149, 2001.

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Report prepared by: Robert Crum
Reviewed by: James Wood
Reviewed by: Molly McKaughan
Program Officer: Rosemary Gibson
Program Officer: Pamela S. Dickson

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