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PubMed1998

Who's your best customer?

Conventional wisdom holds that the best customers and prospects for managed care are the healthiest consumers. This is true only because of the meager extent to which premiums can be adjusted for varying risk among individuals. If a decent health/risk adjustment system were used, the best consumers for managed care to go after would be the highest-risk, highest users of health care, provided only that risk and use can be improved. The healthiest consumers have both the least potential for improvement and the least reasons for loyalty.

Capitation Fee↗
PubMed1988

Disenrollment patterns in Medicare HMOs: a preliminary analysis.

This paper examines disenrollment patterns of 17 Medicare Competition Demonstration HMOs during 1984. Characteristics of HMO disenrollees for a sample of Medicare beneficiaries from two surveys conducted in early 1985 and 1986 are also examined. These data provide a preliminary, descriptive analysis of the nature and the implications of Medicare HMO disenrollment.

Data Collection↗
PubMed1989

Selection of prepaid or fee-for-service care by Medicaid families: examining the health-risk hypothesis.

These results indicate that one PHP, relative to the FFS system, experienced favorable selection on the part of Medicaid AFDC eligibles who have voluntarily enrolled in the plan. Moreover, they suggest the value of adding at least one simple health measure to Medicaid AFDC capitation formulae. The results regarding selection should be considered preliminary because they represent only one PHP-FFS comparison. Data from this PPMHC evaluation, as well as those from other ongoing comparative evaluations of Medicaid eligibles in prepaid and fee-for-service care (e.g., Freund et al., 1989), should provide considerably more information than is currently available on these issues, as well as on issues of the relative impact of PHP and FFS care on utilization and outcomes of Medicaid AFDC eligibles.

Capitation Fee↗
PubMed1989

Evaluation of the Medicare competition demonstrations.

A summary of findings from the Evaluation of the Medicare Competition Demonstrations is presented in this article. The purpose of this evaluation was to examine the implementation and operational experiences of the 26 health maintenance organizations that operated as demonstrations from 1983 to 1985, their experiences in marketing their plans, the factors that affected beneficiaries' decisions to join or not join a plan, the extent to which beneficiaries were satisfied with their choice of plans, the quality of care provided by the plans, and the impact of the demonstrations on Medicare beneficiaries' use and cost of services.

Aged↗
PubMed1999

Risk adjustment wrinkle.

Health plans and providers contracting under Medicare risk want greater equity and the right incentives. Clinical risk adjustment, already being tried in various forms on the private health insurance side, seems to offer a good solution. But the tremendous lack of outpatient data for risk adjustment is throwing up a very big obstacle to the evolution of the Medicare+Choice program, and could result in bad public policy, some industry observers warn. Is the federal government about to make a policy misstep at a critical moment in the Medicare program's development?

Ambulatory Care↗
PubMed1999

No exit? The effect of health status on dissatisfaction and disenrollment from health plans.

OBJECTIVE: To examine the implications of serious and chronic health problems on the willingness of enrollees to switch health plans if they are dissatisfied with their current arrangements. DATA SOURCE: A large (20,283 respondents) survey of employees of three national corporations committed to the model of managed competition, with substantial enrollment in four types of health plans: fee-for-service, prepaid group practice, independent practice associations, and point-of-service plans. STUDY DESIGN: A set of logistic regression models are estimated to determine the probability of disenrollment, if dissatisfied, controlling for the influence on satisfaction and disenrollment of age, race, education, family income and size, gender, marital status, mental health status, pregnancy, duration of employment and enrollment in the plan, number of alternative plans, and HMO penetration in the local market. Separate coefficients are estimated for enrollees with and without significant physical health problems. Additional models are estimated to test for the influence of selection effects as well as alternative measures of dissatisfaction and health problems. DATA COLLECTION: Data were collected through a mailed survey with a response rate of 63.5 percent; comparisons to a subsample administered by telephone showed few differences. PRINCIPAL FINDINGS: In group/staff model HMOs and point-of-service plans, only 12-17 percent of the chronically ill enrollees who were so dissatisfied when surveyed that they intended to disenroll actually left their plan in the next open enrollment period. This compared to 25-29 percent of the healthy enrollees in these same plans, who reported this level of dissatisfaction and 58-63 percent of the enrollees under fee-for-service insurance. CONCLUSIONS: Switching plans appears to be significantly limited for enrollees with serious health problems, the very enrollees who will be best informed about the ability of their health plan to provide adequate medical care. These effects are most pronounced in plans that have exclusive contracts with providers. We conclude that disenrollment provides only weak safeguards on quality for the sickest enrollees and that reported levels of dissatisfaction and disenrollment represent inaccurate signals of plan performance.

Adult↗
PubMed1999

The Federal Employees Health Benefits Plan: implications for medicare reform.

This paper suggests that the Federal Employees Health Benefits Program (FEHBP) is perhaps a model for Medicare reform. First, we introduce the FEHBP and describe important features, such as the method for determining the government's premium contribution. Second, we examine the cost performance of the FEHBP program, and conclude that the FEHBP has out-performed private health insurance programs and Medicare in its ability to control costs. Third, we discuss the problem of adverse selection in the FEHBP. We conclude that the FEHBP has experienced some selection problems, but not enough to prevent it from offering a wide variety of choices without standardized benefits or direct risk adjustment. For a demonstration of competitive pricing in Medicare, the fourth section compares the FEHBP to two models of Medicare reform: "FEHBP for Medicare," proposed by Butler and Moffit; and the "Denver design."

Competitive Bidding↗
PubMed1999

Population choice and variable selection in the estimation and application of risk models.

This paper shows that risk adjustment models based on demographic and employment variables are not easily transferable from one population to the next, and that administrative variables are not useful in predicting medical expenditures. We found statistically significant differences between models built on populations of employees from a single employer enrolled in two different health plans, and between models built on populations of enrollees from a single health plan employed at two different companies. Employment-based variables (e.g., length of employment) had little predictive power in any of these risk models. We conclude that policymakers should be careful in applying risk models across populations, and that future versions of risk models for use within large employers need not include employment-based variables.

Adult↗