May 2002

Grant Results


In 2000 and 2001, PDF Incorporated (now PDF, LLC), Chevy Chase, Md., prepared a policy paper on improved coordination between the fee-for-service Medicare program and community-based social services.

Many health maintenance organizations (HMOs) participating in the Medicare system have instituted processes to identify elderly patients at risk for deteriorating health and to help them access community-based social services.

Standard (non-HMO) fee-for-service Medicare historically has restricted its focus to medical care and has not developed a link to social service agencies. The principal investigator is a consultant and an author specializing in managed care. His previous involvement in Robert Wood Johnson Foundation (RWJF)-funded projects has included directorship of Chronic Care Initiatives in HMOs, a RWJF national program charged with identifying, demonstrating, evaluating, and disseminating innovations in the health care of chronically ill people enrolled in prepaid managed care organizations.

Key Results

  • For this project, the principal investigator:
    • Interviewed HMO representatives, geriatric care professionals, and personnel from community, state, and federal agencies serving the elderly.
    • Reviewed health-care-related publications, HMO policies, and government documents, including the budget of the federal Administration on Aging (AOA).
    • Met with 20 people knowledgeable in the field to discuss his paper's first draft. That meeting was held November 3, 2000, in Washington under the auspices of the Health Insurance Reform Project, a separate RWJF-funded initiative at George Washington University in Washington, D.C. (ID#s 030390, 035292, 041223, and 041828). (For a list of those attending the meeting, see the Appendix.)
  • The resultant 22-page paper — Medicare and Community-Based Social Services: A Tale of Two Silos — included the following points:
    • The U.S. medical care and social service systems interact infrequently, resulting in "cultural silos" — social systems that, while vertically integrated, are worlds unto themselves — and this lack of interaction is mirrored in our institutions of government.

      Responsibility for medical and psycho-social issues is divided among different staffs in the executive branch and different committees in Congress. There is a similar lack of coordination in state and local government. This fragmentation results in missed opportunities to help beneficiaries and achieve savings.
    • For many beneficiaries, medical and psycho-social problems are two sides of the same coin, and failure to address both can lead to a downward spiral for the beneficiary. For example, loneliness can lead to depression, which can lead to a beneficiary's high use of medical resources, including emergency room care and hospitalization.
    • Many HMOs with Medicare contracts have concluded that cost containment will increasingly depend on preventing enrollees from deteriorating to the point of needing inpatient care. Key to this effort is case management and disease management, with coordination of both social and medical services being integral to these activities.
    • The nation's approximately 670 Area Agencies on Aging (AAAs) — which are authorized by the Older Americans Act and funded through AOA — fill some social service needs of chronically ill or disabled seniors. But the AAA programs are not comprehensive, and social problems may be addressed in isolation of the medical system.
    • The federal government could create a new funding program to subsume some of AOA's current functions. Under the new program, its grantees would be required to ensure that case management and related social service referrals were coordinated with the beneficiaries' primary care physicians. Grantees might also be required to meet other conditions, such as providing programs to address key geriatric conditions, including physical inactivity and selected common diseases.
    • The new program could be structured to make formula grants to the states, which could either administer the funds directly, or through intermediaries, such as AAAs or local governments.

      A second option would be to give physicians per capita funding for their patients who met simple screening criteria similar to those now used by HMOs to identify high-risk Medicare beneficiaries. The physicians would use the money to purchase case management and other services from approved agencies.
    • Under either option, a limited budget would be available for items and services that supplement Medicare and have the potential for reducing emergency room or hospital use. This could include minor home repairs, such as installing grab bars in the bathroom, and providing transportation to senior citizen centers.
  • A modified version of the paper has been published in Innovations: The Journal of the National Council on the Aging. In October 2000, the author briefed the American Association of Retired People's (AARP) legislative council on improving care for the chronically ill.

RWJF supported the project with $39,300 between July 2000 and December 2001.

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Preparing a Policy Paper on How Fee-for-Service Medicare Can Relate to Community-based Social Services


PDF Incorporated (Chevy Chase,  MD)

  • Amount: $ 39,300
    Dates: July 2000 to December 2001
    ID#:  039402


Peter D. Fox, Ph.D.
(301) 718-1015

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Appendix 1

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Attendees at the November 3, 2000, meeting in Washington, D.C., convened to discuss the first draft of the policy paper, "Medicare and Community-based Social Services: A Tale of Two Silos."

Sherry Aliotta
SA Squared
Boston, Mass.

Nancy Barrand
The Robert Wood Johnson Foundation
Princeton, N.J.

Richard Besdine, M.D.
Brown University
Providence, R.I.

Sally Coberly
National Health Policy Forum
Washington, D.C.

Rosanne DiStefano
Executive Director
Elder Services of Merrimack Valley
Lawrence, Mass.

Lynn Etheredge
Health Insurance Reform Project
Washington, D.C.

Sandra Foote
Health Insurance Reform Project
Washington, D.C.

Maria Friedman
Health Affairs
Bethesda, Md.

Mary Harahan
Independent Consultant
McLean, Va.

Brian Hayes, M.D.
Independence Blue Cross
Philadelphia, Pa.

Diane Justice
Administration on Aging
Washington, D.C.

Lynn Kellogg
Region IV Area Agency on Aging
St. Joseph, Mich.

Kathryn Leitch
Fulton County Office on Aging
Johnstown, N.Y.

Patricia MacTaggart
Health Care Financing Administration
Baltimore, Md.

Monette McKinnon
National Association of Area Agencies on Aging
Washington, D.C.

Pamela Piering
Aging and Disability Services
Seattle, Wash.

Judith Riggs
Alzheimer's Association
Washington, D.C.

Robert Schreiber, M.D.
Lahey Clinic
Boston, Mass.

Sharman Stephens
Health Care Financing Administration
Baltimore, Md.

Nancy Whitlaw
National Council on Aging
Washington, D.C.

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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.)


Fox PD. "A Tale of Two Silos:  Medicare and Community-Based Social Services. Innovations: The Journal of the National Council on the Aging, 30(4): 8–14, 2002.

Presentations and Testimony

Peter D. Fox, "Improving Care for the Chronically Ill: Suggested Approaches for Fee-for-Service Medicare," to AARP Legislative Council, October 1, 2001, Washington, D.C.

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Report prepared by: Avery Hart
Reviewed by: Michael H. Brown
Reviewed by: James Wood
Program Officer: David C. Colby