The closing of a social HMO: a case study.

A social health maintenance organization (SHMO) integrates acute and long-term care and provides an extended-care benefit for elderly who are at risk of institutionalization. This article reports findings from a case study of the termination of the Group Health SHMO in Minnesota. Interviews were conducted with social workers and at-risk elderly who had been receiving long-term care through the SHMO. The case study examines the post-SHMO transition and the process of replacing SHMO care coordination and longterm care services. Most of the elderly and their caregivers indicated they were "losing ground"--that is, they were paying more or getting less care. Some were paying more for less care. Because they tended to switch to private-pay arrangements and to rely more on informal care, it appears that their care system became much less stable after the closing of the SHMO.

Financial performance in the social health maintenance organization, 1985-88.

Since early 1985, four social health maintenance organizations have delivered integrated health and long-term care services to Medicare beneficiaries under congressionally mandated waivers that included shared public-program risk for losses. Three of four sites had substantial losses in the first 3 years, primarily because of slow enrollment and resultant high marketing and administrative costs. After assuming full risk, two of the three showed surpluses in 1988. Service and management costs for expanded long-term care were similar across sites and were affordable within the framework of Medicare and Medicaid reimbursement and private premiums.

Pulmonary function in chronic renal failure patients managed by continuous ambulatory peritoneal dialysis.

The influence of intraperitoneal fluid on pulmonary function was studied in 20 unselected continuous ambulatory peritoneal dialysis (CAPD) patients, all but one of whom had at least one cardiorespiratory disorder. Measurements of pulmonary function were made with the abdomen empty and following the instillation of 2 1 of dialysis fluid (full). Functional residual capacity fell with the peritoneal cavity full, due to decreases in residual volume, and expiratory reserve volume, but there was a corresponding increase in inspiratory capacity. The vital capacity remained unchanged and the total lung capacity fell only slightly. The FEV1, diffusing capacity, and distribution of ventilation were unaltered. These findings can be attributed to an increase in intra-abdominal pressure resulting in elevation of the diaphragm and increased diaphragmatic contractility. We conclude that the instillation of 21 of dialysis fluid in CAPD patients with cardiorespiratory disease does not result in a clinically significant deterioration in these aspects of pulmonary function.