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PubMed1988

On taking chances with the law of large numbers.

An increasing number of major purchasers of health services now consider capitation to be the preferred method of payment for individual physicians and small group practices. This paper is a primer on capitation payment plans for small risk pools. It describes some of the basic economic issues that purchasers and providers face when negotiating small-panel capitation contracts, including sources of risk, techniques of risk reduction and risk sharing. An empirical section analyses the experience of a plan that took a chance with the law (law of large numbers) and lost.

Capitation Fee↗
PubMed1998

Managed care for elderly people: a compendium of findings.

Although managed care seems to serve well the interests of non-elderly enrollees and their payers, elderly people face more risks. Chronic conditions, multiple problems, and more limited resources make them more vulnerable, whereas multiple payer sources make them more complicated to cover. This synthesis of managed care delivered in Medicare and Medicaid demonstration projects serving elderly beneficiaries shows that managed care plans either select or attract enrollees who suffer fewer frailties than those served in fee-for-service settings, exhibit reluctance to enter rural markets, provide a broad range of elderly-specific services, offer more comprehensive coverage and services, and result in greater perceived access problems, particularly for vulnerable subgroups. Plans operate more cheaply by using fewer resources, even after adjusting for case mix differences. Managed care enrollees tend to be more satisfied with financial and coverage aspects, whereas fee-for-service enrollees report higher satisfaction on other dimensions. In acute care settings, process of care findings were mixed, whereas clinical and self-reported outcome indicators were no better and in some instances worse in managed care. Long-term care enrollees, in the few studies reported, consistently faired worse in both the processes and outcomes of care. These findings suggest that further research on the effects of managed care in its rapidly changing incarnations is needed, particularly with respect to how to improve the quality of acute and long-term care delivered to elderly people and the proper role of government and other key actors in the health care system.

Aged↗
PubMed2002

From physician to consumer: the effectiveness of strategies to manage health care utilization.

Many strategies are commonly used to influence physician behavior in managed care organizations. This review examines the effectiveness of three mechanisms to influence physician behavior: financial incentives directed at providers or patients, policies/procedures for managing care, and the selection/education of both providers and patients. The authors reach three conclusions. First, all health care systems use financial incentives, but these mechanisms are shifting away from financial incentives directed at the physician to those directed at the consumer. Second, heavily procedural strategies such as utilization review and gatekeeping show some evidence of effectiveness but are highly unpopular due to their restrictions on physician and patient choice. Third, a future system built on consumer choice is contradicted by mechanisms that rely solely on narrow networks of providers or the education of physicians. If patients become the new locus of decision making in health care, provider-focused mechanisms to influence physician behavior will not disappear but are likely to decline in importance.

Case Management↗
PubMed2001

Provider choice and utility loss due to selective contracting in rural and urban areas.

An econometric model estimated the disutility of traveling long distances for depression treatment, and simulations calculated the utility loss associated with selective contracting in rural and urban areas. A representative sample of depression patients (n = 106) and all practicing providers (n = 3,710) in Arkansas were identified and the distances between them were calculated. Using discrete choice analysis, patient preferences for provider type and travel distance were estimated. Simulations calculated the utility loss associated with alternative scenarios of selective contracting. Provider type and distance were significant predictors of provider choice. To equate the utility loss associated with selective contracting in rural and urban areas, a slightly higher proportion of rural physicians and a substantially higher proportion of rural mental health specialists must be contracted. To avoid further reductions in geographic access, managed care organizations should contract with a higher proportion of rural providers than urban providers.

Arkansas↗
PubMed2005

VA-Medicare dual beneficiaries' enrollment in Medicare HMOs: access to VA, availability of HMOs, and favorable selection.

This study examined the association between Veterans Administration (VA)-Medicare dual beneficiaries' HMO enrollment and factors including sociodemographics, access/attachment to VA, self-reported health status, and characteristics of Medicare HMO markets. The results showed that availability of Medicare HMOs and less access to VA care were the major predictors of VA-Medicare dual beneficiaries' HMO enrollment. Other significant predictors of HMO enrollment were age (65-69), having no college education, VA priority status (low income; less than 50 percent service disability). There was some evidence of favorable selection measured by self-reported health status. The identified HMO enrollment profile can position VA better in attracting and managing the care of these beneficiaries and in meeting potentially large shifts in their need for VA care if Medicare benefits or policies change markedly.

Aged↗
PubMed1999

Survival and treatment for colorectal cancer Medicare patients in two group/staff health maintenance organizations and the fee-for-service setting.

The current study compares treatment use and long-term survival in colorectal cancer patients between Medicare beneficiaries enrolled in two large prepaid group/staff health maintenance organizations (HMOs) and the fee-for-service (FFS) setting. The study is based on 15,352 colorectal cancer cases diagnosed between 1985 and 1992 and followed through 1995. Survival differences between the HMO and FFS cases were assessed using Cox regression. Treatment differences were evaluated using logistic regression. HMO cases had a lower overall mortality than did FFS cases but not a significantly lower colorectal cancer-specific mortality. Use of surgical resection was similar between HMO and FFS cases. However, rectal cancer cases in the HMOs were more likely to receive postsurgical radiation therapy than FFS cases. Superior overall survival in the HMOs may be the result of increased colorectal cancer screening, greater use of adjuvant therapies, and selection of healthier individuals.

Aged↗
PubMed2000

Does chronic illness affect the adequacy of health insurance coverage?

Although chronically ill individuals need protection against high medical expenses, they often have difficulty obtaining adequate insurance coverage due to medical underwriting practices used to classify and price risks and to define and limit coverage for individuals and groups. Using data from healthy and chronically ill individuals in Indiana, we found that chronic illness decreased the probability of having adequate coverage by about 10 percentage points among all individuals and by about 25 percentage points among single individuals. Preexisting condition exclusions were a major source of inadequate insurance, though not the only cause. Our results emphasize the impact of enforcing the Health Insurance Portability and Accountability Act (HIPAA) of 1997, which limits preexisting condition exclusions.

Adult↗
PubMed1994

The Oregon Health Plan and public health.

The Oregon Health Plan would provide all Oregonians with health insurance through a combination of Medicaid expansion, employer mandates and high-risk coverage, with services delivered largely through managed care. The role of public health in a managed care environment is an important national issue, and one which has received much attention in Oregon. "Cultural" differences between Medicaid and public health have arisen over issues such as whether eligibility assures access, whether the private medical model will provide integrated care, the potential for exploitation of vulnerable populations in a capitated system, and the loss of cost-based Medicaid reimbursement to public clinics. In 1991, legislation required that Oregon's Medicaid managed care plans enter agreements with local health departments to assure their continued participation in providing certain public health services; these agreements are now being implemented. Oregon's experience suggests that any national health system will require a continuum of community and individual health services, with an important role for public health departments.

Health Benefit Plans, Employee↗
PubMed1997

Everybody into the pool! Medicare in the twenty-first century.

Both the President and now Republicans have proposed to slow the growth of Medicare costs by allowing seniors to join private managed care health insurance plans. In this article, the author demonstrates that a private market in health insurance will not function like a "normal" commercial insurance market, will constantly be undermined by adverse selection, and therefore is unlikely to achieve the objectives for which it is being created. This result follows from established principles of commercial insurance and our modern understanding of the pathophysiology of disease.

Aged↗
PubMed1998

Self-Insured health care plans: are they fair to employees with HIV/AIDS?

A literature search reveals a number of instances where people with AIDS (PWAs) have limits placed on their health care by self-insured firms. Some firms cite the high cost of health care for AIDS as the motivation for their decision. Research demonstrates, however, that AIDS is not the only high-priced disease to treat. Treatment for lung cancer is costly as well. In many cases, unprotected sex leads to HIV/AIDS and lung cancer is strongly linked to tobacco use. Therefore, lung cancer can be studied as a comparison disease for issues relating to health care coverage of PWAs. A literature search also shows that no examples of limitations on health care were found among lung cancer patients. A 1992 Supreme Court decision did not restrict the inequitable access to health care through self-insured plans for AIDS patients. When employees of self-insured firms exhaust their insurance benefits, which can occur quickly, they apply for Medicaid or Medicare benefits. As a result, the government's burden is increased in the care of PWAs. The issue, therefore, should be to ensure that employees of self-insured firms have equal access to health care since there are other serious diseases, such as lung cancer, that are also expensive to treat.

Acquired Immunodeficiency Syndrome↗
PubMed2004

A comparison snapshot of states' small group market reform on access and enhancing valued plan features, 1999.

Small group health insurance statutes of 48 states and the District of Columbia, as of 1999, were reviewed. Reform provisions judged to have some relevance for the market are catalogued and total 74 distinct regulations. Judgment of market relevance was based on actuarial experience at a leading health insurance company. The regulations are categorized under: (1) Access improvement; (2) Pricing and Rating Reforms; (3) Improving stability of coverage; and (4) Improving valued features of plans. The nuances and variety of these regulations, adopted in various combinations by the states, are discussed. The complexity of the reform scenario suggests the need for impact studies that take into account the totality of reform. Past studies have evaluated the impact of selected major reforms in isolation, and, thus, have been inadequate to provide definitive conclusions on the reforms' impact.

Actuarial Analysis↗