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PubMed2005

Health plan switching among members of the Federal Employees Health Benefits Program.

This paper examines factors associated with switching health plans in the Federal Employees Health Benefits Program. Switching plans is not uncommon, with 12% of members switching plans annually. Individuals switch out of plans with premium increases and benefit decreases relative to other plans in the market. Switching is negatively associated with age due to increasing switching costs associated with age rather than decreasing premium sensitivity. Individuals in preferred provider organizations are less likely to switch, but are more responsive to premium increases than those in the managed care sector. Those who do switch plans are likely to switch to a different plan in the same sector.

Adult↗
PubMed2004

Evaluation of the effect of a consumer-driven health plan on medical care expenditures and utilization.

OBJECTIVE: To compare medical care costs and utilization in a consumer-driven health plan (CDHP) to other health insurance plans. STUDY DESIGN: We examine claims and employee demographic data from one large employer that adopted a CDHP in 2001. A quasi-experimental pre-post design is used to assign employees to three cohorts: (1) enrolled in a health maintenance organization (HMO) from 2000 to 2002, (2) enrolled in a preferred provider organization (PPO) from 2000 to 2002, or (3) enrolled in a CDHP in 2001 and 2002, after previously enrolling in either an HMO or PPO in 2000. Using this approach we estimate a difference-in-difference regression model for expenditure and utilization measures to identify the impact of CDHP. PRINCIPAL FINDINGS: By 2002, the CDHP cohort experienced lower total expenditures than the PPO cohort but higher expenditures than the HMO cohort. Physician visits and pharmaceutical use and costs were lower in the CDHP cohort compared to the other groups. Hospital costs and admission rates for CDHP enrollees, as well as total physician expenditures, were significantly higher than for enrollees in the HMO and PPO plans. CONCLUSIONS: An early evaluation of CDHP expenditures and utilization reveals that the new health plan is a viable alternative to existing health plan designs. Enrollees in the CDHP have lower total expenditures than PPO enrollees, but higher utilization of resource-intensive hospital admissions after an initially favorable selection.

Choice Behavior↗
PubMed1998

Features of employment-based health plans.

This Issue Brief focuses on changes to the health care financing and delivery system as implemented by employers. It discusses health plan costs, cost sharing, plan funding, health care delivery systems, services covered under various health plan types, coverage limitations, and retiree health coverage. National health expenditures are estimated at $1.035 trillion, representing 13.6 percent of Gross Domestic Product in 1996, up from $699.5 billion and 12.2 percent in 1990. Rising health care spending is also evident at the employer level: In 1996, employer spending on private health insurance totaled $262.7 billion, up from $61.0 billion in 1980. Business health spending as a percentage of total compensation increased from 3.7 percent in 1980 to a high of 6.6 percent in 1993, and declined to 5.9 percent in 1996. Employment-based health plans are the most common source of health insurance coverage among the nonelderly population in the United States, providing coverage to nearly two-thirds of those under age 65. Despite the growth of many cost-sharing provisions, individuals are paying a smaller percentage of total health care costs. In 1960, 69 percent of private health care expenditures were paid out of pocket. Between 1993 and 1996, only 37 percent of private health expenditures were paid out of pocket. One of the most significant developments of the 1980s, which has continued throughout the 1990s, is the growth of managed care plans. As recently as 1994, traditional indemnity plans were the most commonly offered type of employment-based health plan. As fewer employers offered traditional indemnity plans, participation in these plans declined and participation in managed care plans increased. In 1997, 15 percent of employees participating in a health plan were enrolled in an indemnity plan, compared with 52 percent in 1992. Since 1993, employment-based health benefit cost inflation has been virtually nonexistent. Employers have kept cost increases low by using managed care and making other changes. Workers have been shifted to, have been induced to choose, or have voluntarily selected managed care health plans. Preferred provider organization (PPO) and point-of-service (POS) plans have experienced relatively strong gains in enrollment. Employers have also increased the use of utilization review for active workers, and cut back on health benefits for retirees. These changes are in stark contrast to the pre-1993 period, which saw even faster change, with rising health care costs and increasing deductibles and coinsurance for workers in non-HMOs.

Cost Sharing↗
PubMed1992

HMOs outscore both PPOs, traditional indemnity plans in degree of customer satisfaction.

A higher percentage of participants in health maintenance organizations say they are satisfied with their health plans than are those who have traditional indemnity plans or are enrolled in preferred provider organizations. The results, derived from a new study of consumer satisfaction, also show that 85% of Americans who have health insurance coverage say they are satisfied with those plans.

Age Factors↗
PubMed1986

Recent developments in organizing and financing health-care services.

Recent developments in the organization and financing of health-care services are described. All recent developments reflect an effort by both private and public payers to restrict use of health-care services, as well as to control price. Private use-review programs, such as second-surgical-opinion services and case-management services, are increasingly being used. The number of hospital admissions and length of patient stay continue to decline, but, because of increasing complexity of care, the cost of pharmaceutical services has not decreased proportionately. Points relating to health-care financing in the federal reconciliation budget effective May 1, 1986, are reviewed, as are other new federal regulations affecting the structure of services and terms of reimbursement under the Medicare and Medicaid programs. For Medicare, these include new scope objectives for professional review organizations, decreased return-on-equity payments to for-profit hospitals for outpatient services and to skilled nursing facilities, and elimination of waiver-of-liability presumptions for hospitals. Also, physicians must now identify specific services provided during each inpatient hospital visit. Most developments related to home health-care services pertain to limiting the cost of durable medical equipment. Alternative types of health care based on capitation funding, such as health maintenance organizations, competitive medical plans, and preferred provider organizations, will continue to grow in both the public and private sectors, and the use of private use-review programs for controlling costs is expected to accelerate in the next year.

Delivery of Health Care↗
PubMed1988

A primer on how to analyze contracts and avoid the traps.

Contracts from preferred provider organizations, health maintenance organizations, independent practice associations, and managed health plans present numerous problems for primary care physicians. The ability to understand the terms and conditions is an essential part of the practice of medicine today. Additionally, physicians need to involve experts in the preparation of counterproposals that will render contracts fair and equitable for physicians. The blind acceptance of a contract may dramatically increase a physician's liability exposure. Although contracts have become a permanent fixture in the current health care delivery environment, physicians can formulate informed and intelligent responses. They and their office personnel can learn basic analysis techniques of such documents that will aid in surviving the onslaught of contracts.

Contract Services↗
PubMed1995

A national survey of the arrangements managed-care plans make with physicians.

BACKGROUND: Despite the growth of managed care in the United States, there is little information about the arrangements managed-care plans make with physicians. METHODS: In 1994 we surveyed by telephone 138 managed-care plans that were selected from 20 metropolitan areas nationwide. Of the 108 plans that responded, 29 were group-model or staff-model health maintenance organizations (HMOs), 50 were network or independent-practice-association (IPA) HMOs, and 29 were preferred-provider organizations (PPOs). RESULTS: Respondents from all three types of plan said they emphasized careful selection of physicians, although the group or staff HMOs tended to have more demanding requirements, such as board certification or eligibility. Sixty-one percent of the plans responded that physicians' previous patterns of costs or utilization of resources had little influence on their selection; 26 percent said these factors had a moderate influence; and 13 percent said they had a large influence. Some risk sharing with physicians was typical in the HMOs but rare in the PPOs. Fifty-six percent of the network or IPA HMOs used capitation as the predominant method of paying primary care physicians, as compared with 34 percent of the group or staff HMOs and 7 percent of the PPOs. More than half the HMOs reported adjusting payments according to utilization or cost patterns, patient complaints, and measures of the quality of care. Ninety-two percent of the network or IPA HMOs and 61 percent of the group or staff HMOs required their patients to select a primary care physician, who was responsible for most referrals to specialists. About three quarters of the HMOs and 31 percent of the PPOs reported using studies of the outcomes of medical care as part of their quality-improvement programs. CONCLUSIONS: Managed-care plans, particularly HMOs, have complex systems for selecting, paying, and monitoring their physicians. Hybrid forms are common, and the differences between group or staff HMOs and network or IPA HMOs are less extensive than is commonly assumed.

Capitation Fee↗
PubMed1997

Managed care in the United States.

Medical care in the United States continues to consume an increasing amount of the Gross Domestic Product. To control the rising costs of health care many industries have turned to a controlled form of financing and delivery of health care--often referred to as managed care. Many types of managed care exist, including preferred provider organizations (PPO), exclusive provider organization (EPO), and health maintenance organizations (HMO). HMOs involve prepaid premiums, limited panels of providers and assumption of financial risk on the part of the providers. A variety of HMOs are currently operating in the United States. Managed care involves taking risks by those who administer it. Some methods of controlling patient and physician behaviour by taking risks are capitation, risk pools and withholds. With capitation the physician is paid a 'per member per month' fee regardless of whether the patient uses the service. Risk pools are concerned with who shares the risk; for example, the primary physician shares the financial risk with specialists. Withholds involve a fee-for-service with a portion withheld which may be returned to the provider if he/she is parsimonious. A concern expressed about HMOs is the possibility of restricted services. Moreover, hospital expenses make up a large portion of the total health care dollar. In 1995 the average length of stay for a Medicare patient was 6.1 days as opposed to 3.9 days for the non-Medicare patient. Indeed, HMOs were the leaders in the development of same-day surgery and out-patient treatment. Increasingly, in the United States, public and social insurance plans are turning to managed care as a method to control health care expenditure. Some government insurance plans, such as Medicare and Medicaid, also increasingly offer managed health options. The trend, for now, in the United States increases enrollment in managed care plans. Although this is occurring at a rapid pace, managed care will probably not be the final solution to provision of medical care in the United States.

Cost Control↗
PubMed1985

Competitive alternatives to hospital inpatient care.

Reasons for the heightened national interest in alternative health-care delivery systems, competitive forces and hospital-use patterns, and three major alternatives to inpatient hospital care are discussed. The Reagan Administration's policies on health-care incentives reform, the federal emphasis on prospective pricing systems, increased rate-regulation roles for the states, and growing employer concern over the cost of health benefits have all contributed to the increased interest in alternative delivery systems. Demand for inpatient hospital care is declining and will continue to decline. In addition to changes in the financing mechanisms for third-party payers, there are three broad competitive forces reducing the demand for hospital inpatient care. These are the growth and diversification of ambulatory care, the development of aftercare for chronically ill and elderly patients, and the expansion of alternative delivery systems. Ambulatory-care centers, preferred provider organizations, and health maintenance organizations are discussed, and their impact on hospitals, pharmacists, and the health-care system is evaluated. Trends in the development of these alternatives are described. Competition is forcing hospitals and health-care providers to consider options such as aftercare, alternative delivery systems, ambulatory care, and multihospital systems in order to survive in today's health-care system.

Aftercare↗
PubMed1988

Health care delivery systems in review.

Plagued with insolvency, physician discontent, and employer demands, the health maintenance organization (HMO) industry is seeking solutions to their crippling ailments. As buyers are more difficult to find for troubled plans, some executives are forced to resign or face bankruptcy. Still other executives have been able to turn around their financial and physician staffing challenges. The preferred provider organization (PPO) industry remains in the background of the HMO turmoil, facing the issues of quality assurance and cost containment.

Financial Management↗
PubMedDate not supplied

Geography and destiny: local-market perspectives on developing Medicare Advantage regional plans.

The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 established regional preferred provider organizations (PPOs) as a new private-plan option for beneficiaries in the Medicare Advantage (MA) program, starting in 2006. Developing network-based Medicare products uniformly priced across statewide or multistate regions presents unprecedented challenges and opportunities for health insurers. We held discussions with local health plan and hospital informants in six of the twelve Community Tracking Study (CTS) communities to obtain their perspectives on key considerations in evaluating whether they can and will offer regional PPO products under the MA program.

Aged↗
PubMed1992

Barriers to pediatric referral in managed care systems.

Anecdotal evidence suggests that children's access to pediatric subspecialty and inpatient care is hampered by referral barriers imposed by managed care systems. To identify such barriers and determine how they affect the referral process, a sample of American Academy of Pediatrics Fellows (n = 1598) was surveyed. The response rate was 79.1% (n = 1264). Of those pediatricians in direct patient care (n = 956), 71.4% participated in a managed care plan. Pediatricians referred patients in managed care systems somewhat less frequently than in traditional pay systems: 8.7% and 6.9% referred managed care patients to subspecialists and inpatient care, respectively, less often. More than 20% and 10% of pediatricians with patients in managed care systems had at least one referral to subspecialist care and inpatient care, respectively, denied in the previous year. Pediatricians experienced more barriers in preferred provider organizations than in health maintenance organizations. These data suggest that utilization management programs, such as those used in managed care systems, may limit necessary access to pediatric subspecialty and inpatient care.

Child↗
PubMed1984

Less is more? Today's economics and its challenge to psychiatry.

Escalating costs of medical and psychiatric care have prompted a reevaluation of the health care delivery system and practice styles. There are several "procompetition" or market-based solutions that seek to make the consumer of care more price conscious and the provider of care more cost conscious. Diagnosis-related groups (DRGs), preferred provider organizations (PPOs), the growth of for-profit hospital systems, and the expansion of health maintenance organizations (HMOs) are reshaping the organization and financing of psychiatric care. Psychiatry's adaptation to the new medical economics must emphasize the quality of patient care.

Delivery of Health Care↗
PubMed2002

The effect of payer type on orthopaedic practice expenses.

BACKGROUND: Orthopaedic practice expenses are the costs associated with providing treatment that are incurred by a physician's practice. Certain payer types are thought to increase orthopaedic practice expenses by increasing paperwork and other administrative activities. Our study investigated the hypothesis that orthopaedic practice expenses would vary significantly by payer type. METHODS: With use of the method of activity-based costing, data on the orthopaedic practice expenses for 518 consecutive patients (286 men and 232 women) who had a sports-related knee condition were collected. For each patient enrolled in the study, all employees recorded the actual amount of time that they spent on each of seventeen specific activities previously shown to be associated with orthopaedic practice. The seventeen activities were categorized as either a value-added activity, which adds value to the services provided to the patient, or a nonvalue-added activity, which does not add value. The total orthopaedic practice expense was the sum of the value-added and nonvalue-added activity expenses. To capture all practice expenses associated with a particular episode of care, data collection continued until the patient was discharged and the financial account had been settled. We evaluated the differences in orthopaedic practice expenses among six payer types: self-pay, indemnity plan, Medicare, health maintenance organization/point-of-service plan (HMO/POS), preferred provider organization (PPO), and Workers' Compensation. RESULTS: The differences among payer types with respect to orthopaedic practice expenses were significant (p = 0.0000000004). The total orthopaedic practice expense per episode of care was $123 for self-pay, $195 for an indemnity plan, $148 for Medicare, $178 for PPO, $208 for HMO/POS, and $299 for Workers' Compensation. These differences among payer types persisted even after accounting for patient age, gender, treatment type (nonoperative versus operative), and number of office visits. Nonvalue-added activity expenses differed to a greater degree among the payer types than did value-added activity expenses. CONCLUSIONS: The payer type was found to be an important factor affecting orthopaedic practice expenses, particularly with respect to nonvalue-added activity expenses.

Adult↗
PubMedDate not supplied

Utilization, patient satisfaction, and cost implications of acupuncture, massage, and naturopathic medicine offered as covered health benefits: a comparison of two delivery models.

CONTEXT: Increasing numbers of health plans in the United States offer complementary and alternative medicine (CAM) benefits despite limited information. OBJECTIVE: To determine the utilization rates and costs associated with providing CAM services in 2 benefit designs, and to determine the satisfaction of patients in both plans. DESIGN: Two health plans were identified: a traditional indemnity plan offered through a defined preferred provider organization (PPO) of CAM providers and a health maintenance organization (HMO). Costs and utilization rates for CAM services were compared during a 1-year period of coverage beginning November 1, 1996. SETTING AND PARTICIPANTS: 1091 patients in both plans who used CAM services during the month of May 1997 in Washington state. RESULTS: Only 1% of all patients covered for CAM accessed these services during the study period. A significantly higher percentage of patients in the PPO plan (1.2%) used CAM services compared to the HMO plan (0.6%) (P < .001). However, the average total cost of annual CAM services (plan benefit + user contribution) was similar ($347 in the HMO and $376 in the PPO), and the price per member per month was nearly identical ($0.20 in the HMO and $0.19 in the PPO). Most users perceived these services as helpful. CONCLUSIONS: Utilization of CAM services and per member per month costs were lower than expected given the high interest in CAM services reported in consumer surveys. The high level of satisfaction with CAM services and self-reported decrease in the use of pain medications suggests the need for prospective studies examining the effect of CAM treatments.

Acupuncture Therapy↗
PubMedDate not supplied

The critical role of ERISA in state health reform.

Despite prominent roles for employers and state regulation in the Clinton administration's Health Security Act, relatively little attention has been accorded to the impact of federal preemption of state legislation through the Employee Retirement Income Security Act (ERISA). As interpreted by the U.S. Supreme Court, ERISA permits state regulation of insured employee health plans but otherwise preempts analogous regulation relating to self-insured benefit plans. This has prompted lower courts to find that hospital rate-setting legislation, regulation of preferred provider organizations (PPOs), and medical malpractice suits for utilization review decisions are preempted by ERISA. Several issues with major implications for health reform remain unresolved, such as the availability of ERISA preemption to self-insured health alliances and health maintenance organizations (HMOs).

Health Benefit Plans, Employee↗
PubMed2000

Wrestling with typology: penetrating the "black box" of managed care by focusing on health care system characteristics.

The health care system has undergone a fundamental transformation undermining the usefulness of the typology of the health maintenance organization, the independent practice association, the preferred provider organization, and so forth. The authors present a new approach to studying the health care system. In matrix form, they have identified a set of organizational and delivery characteristics with the potential to influence outcomes of interest, such as access to services, quality, health status and functioning, and cost. The matrix groups the characteristics by domain--financial features, structure, care delivery and management policies, and products--and by key roles in the health care system--sponsor, plan, provider intermediary organization, and direct services provider. The matrix is a tool for researchers, administrators, clinicians, data collectors, regulators, and other policy makers. It suggests a new set of players to be studied, emphasizes the relationships among the players, and provides a checklist of independent, control, and interactive variables to be included in analyses.

Data Collection↗
PubMed2000

NCQA moves toward PPO accreditation.

The National Committee for Quality Assurance has introduced a draft accreditation program for preferred provider organizations that focuses on consumer protection, access to care, member services, provider credentialing, medical group oversight, and plan performance.

Accreditation↗