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Medicare will soon undergo major changes, as Medicare beneficiaries are given a complex array of plan options known as Medicare+Choice. These changes are an attempt to extend the financial solvency of Medicare, but they also offer employees an opportunity to redesign their retiree health plans. It is essential that employers are fully informed about the coming changes and communicate with retirees about them.
This study models the relationship between Medicare beneficiary decisions to join Medicare HMOs and subsequent health services utilization. The relationship between health plan choice and utilization is thought to be endogenous because of favorable selection into HMOs. Previous studies found significantly lower inpatient utilization among Medicare HMO enrollees than among nonenrollees, but lacked strong controls for selection bias. Thus, a firm conclusion could not be drawn as to whether the observed differences were attributable to the HMO practice setting or to baseline differences in the illness profiles of the two groups studied. The present study uses simultaneous equations methods, including discrete factor estimation, to test the effect of Medicare HMOs on utilization when strong controls for selection bias are imposed. The model was run on a panel of 1993-1996 data from the Medicare Current Beneficiary Survey, supplemented with linked data on Medicare HMO characteristics and area supply characteristics. The study found that even when favorable selection is controlled for, Medicare HMOs significantly reduce both the probability of hospitalization and the number of inpatient days used by those who are hospitalized. Medicare HMOs do not, however, appear to reduce the use of physician services.
OBJECTIVE: To measure the effects of case management on an older population's costs of health care. DESIGN: A 1-year randomized controlled trial. SETTING: Multiple sites of care in San Francisco, California. PARTICIPANTS: Patients aged 65 or older of primary care physicians in a large provider organization bearing financial risk for their care (n = 6409). INTERVENTION: Screening for high risk and provision of social work-based case management. OUTCOME MEASURES: Volume and cost of hospital, physician, case management, and other health-related services. RESULTS: The experimental group used more case management services than the control group (0.09 vs. 0.02 months per person, P<.001). The experimental group's average total payments for health care were slightly lower ($3148 vs $3277, P = .40). CONCLUSIONS: This study provides no statistically significant evidence that social work-oriented case management reduces the use or the cost of health care for high-risk older people. Other potentially favorable effects of this type of case management need to be evaluated, as do the effects of other types of case management.
OBJECTIVE: Recent Medicare health maintenance organization (HMO) disenrollees use a high level of medical services. This study examined admissions for total hip arthroplasty (THA) and osteoarthritis-related knee replacements (OKR) among Medicare HMO disenrollees and continuously enrolled fee-for-service (FFS) beneficiaries to determine whether Medicare beneficiaries are returning to the FFS system to receive quality-of-life enhancing elective care. STUDY DESIGN: Retrospective analysis of Medicare inpatient claims for elderly Medicare beneficiaries residing in South Florida between 1990 and 1993. METHODS: Inpatient admission rates for THA, OKR, and for 2 acute conditions--total hip replacements related to fracture of the hip (HRF) and acute myocardial infarction (AMI)--were estimated for Medicare HMO disenrollees over the 3-month period immediately following their disenrollment. These rates were compared with standardized rates for Medicare FFS enrollees. RESULTS: The annualized adjusted rates of both THA and OKR were 3.5 to 4 times higher among Medicare HMO disenrollees than among FFS beneficiaries (P < or = .0001 for both procedures); substantially smaller differences were noted for HRF (P < or = .05), and no difference was present for AMI. HMO disenrollees and FFS enrollees did not differ in their levels of comorbidity at the time of admission. CONCLUSIONS: These data provide indirect evidence that Medicare HMOs in South Florida are rationing THA and OKR and that beneficiaries respond by returning to the FFS system to seek care. This apparent rationing has important implications regarding for the management of serious, but nonemergent, medical conditions within the evolving Medicare system.
The Transtheoretical Model (TTM, the "stage model") can guide development of programs to increase Medicare beneficiaries' readiness to make informed health plan choices. In this study, TTM staging algorithms were developed to assess readiness to engage in three types of informed choice: (1) learning about the Medicare program; (2) learning about Medicare health maintenance organizations (HMOs); and (3) reviewing different plan options. Stage of change based on all three algorithms is related to knowledge about the Medicare program and information-seeking. Findings provide evidence for the construct validity of the stage measures and for the applicability of the TTM to informed choice among beneficiaries.
This Federal Register notice seeks the input and recommendations of interested parties into the OIG's development of a compliance program guidance for Medicare+Choice organizations that offer coordinated care plans (M+CO/CCPs). The OIG has previously developed compliance program guidances for hospitals, clinical laboratories and home health agencies in order to provide clear and meaningful guidance to those segments of the health care industry. In an effort to provide similar guidance to certain M+C organizations, we are soliciting comments, recommendations and other suggestions from concerned parties and organizations on how best to develop compliance program guidance and reduce fraud and abuse within M+CO/CCPs.
BACKGROUND: Having annual dollar limits in prescription coverage is a type of benefit design unique to Medicare beneficiaries. This type of coverage is found predominantly within private Medigap policies and Medicare+Choice plans offering prescription coverage. OBJECTIVES: The purpose of this study was to determine the impact of capped prescription benefits on efforts to reduce out-of-pocket prescription expenses by beneficiaries at risk for reaching their cap. RESEARCH DESIGN: This design was quasi-experimental, with data obtained from self-administered questionnaires mailed to 600 Medicare HMO risk enrollees with capped prescription benefits. RESULTS: Data were collected on 378 Medicare enrollees for a 63% response rate. Approximately half of all respondents participated in > or =1 strategy to reduce their out-of-pocket prescription expenses. Participation in selected strategies included obtaining samples from physicians (39.2%), taking less than prescribed amounts (23.6%), and discontinuing prescribed medications (16.3%). Additionally, 15% of respondents indicated going without necessities, and 12% indicated borrowing money to pay for their prescriptions. Those who reached their prescription cap were more likely to participant in any one behavior (odds ratio [OR], 2.18), more likely to take less medication than prescribed (OR, 2.83), more likely to discontinue a medication (OR, 3.36), and more likely to obtain samples from their physician (OR, 2.02) compared with those who had not reached their prescription cap. CONCLUSIONS: Beneficiaries at risk for reaching their prescription cap are taking steps to reduce their out-of-pocket prescription costs. Although some behaviors would be considered prudent, other behaviors may be placing beneficiaries at risk for drug-related morbidity and mortality.
This article reports the results of an analysis of the relationship between supplemental benefits offered by Medicare+Choice (M+C) plans and their plan performance ratings. We examined two measures of plan performance: (1) plan ratings as reported in the Medicare Managed Care (MMC) Consumer Assessment of Health Care Study (CAHPS), and (2) disenrollment rates. The results of our analysis indicated that variations in plan supplemental offerings have little impact on enrollees' plan performance ratings--both overall ratings and access to care measures. Furthermore, disenrollment rates were found to be more sensitive to the availability of alternative M+C plans, either in general, or for specific benefits than to variations in benefit offerings.
The 2001 Survey of Involuntary Disenrollees was conducted to investigate the impact of Medicare+Choice (M+C) plan withdrawals on Medicare beneficiaries. Eighty-four percent of a total of 4,732 beneficiaries whose Medicare managed care (MMC) plan stopped serving them at the end of 2000 responded to the survey. Their responses indicated that the withdrawal of plans from Medicare affected beneficiaries in terms of concerns about getting and paying for care, increased payments for premiums and out-of-pocket costs, and changes in health care arrangements. Of particular concern were the impacts on those in vulnerable subgroups such as the disabled, less educated, and minorities.
INTRODUCTION: The object of this study was to examine the effect of population-based disease management and case management on resource use, self-reported health status, and member satisfaction with and retention in a Medicare Plus Choice health maintenance organization (HMO). METHODS: Study design consisted of a prospective, randomized controlled open trial of 18 months' duration. Participants were 8504 Medicare beneficiaries aged 65 and older who had been continuously enrolled for at least 12 months in a network model Medicare Plus Choice HMO serving a contiguous nine-county metropolitan area. Members were care managed with an expert clinical information system and frequent telephone contact. Main outcomes included self-reported health status measured by the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), resource use measured by admission rates and bed-days per thousand per year, member satisfaction, and costs measured by paid claims. RESULTS: More favorable outcomes occurred in the intervention group for satisfaction with the health plan (P < .01) and the social function domain as measured by SF-36 (P = .04). There was no difference in member retention or mortality between groups. Use of skilled nursing home services was significantly lower in the intervention group than in the control (616 vs 747 days per thousand members per year, P = .02). This reduction, however, did not lead to lower mean total expenditures in the intervention group compared with the control (6828 dollars per member for 18 months vs 7001 dollars, P = .61). CONCLUSION: Population-based disease management and case management led to improved self-reported satisfaction and social function but not to a global net decrease in resource use or improved member retention.
OBJECTIVE: the Medicare Health Outcomes Survey (HOS), a new quality measure in the Health Plan Employer Data and Information Set, is designed to assess physical and mental functional health outcomes of Medicare beneficiaries enrolled in Medicare+Choice organizations. We discuss the rationale for the HOS measure together with methodologic challenges in its use and interpretation, using descriptive data from the baseline Medicare HOS to illustrate some of these challenges. DATA SOURCES/STUDY DESIGN: The 1999 Cohort 2 Medicare HOS baseline data were used for a cross-sectional descriptive analysis. A random sample of 1,000 beneficiaries from each health plan with a Medicare+Choice contract was surveyed (N = 156,842; 282 organizations included in these analyses) . PRINCIPAL FINDINGS: The HOS measure is designed to assess a previously unmeasured dimension of quality. Plan-level variation was seen across all baseline measures of sociodemographic characteristics and illness burden. At the individual level socioeconomic position as measured by educational attainment was strongly associated with functional status. The least educated beneficiaries had the highest burden of illness on all measures examined, and there was a consistent and significant gradient in health and functional status across all levels of education. In analyses stratified by race and ethnicity, socioeconomic gradients in f un ct ion persist ed. CONCLUSIONS Despite limitations, by focusing at t en t ion on the need to improve functional health out comes among elderly Medicare beneficiaries enrolled in Medicare+Choice, the HOS can serve as an important new tool to support efforts to improve health care quality. The HOS provides valuable information at the federal, state, and health plan levels that can be used to identify, prioritize, and evaluate quality improvement interventions and monitor progress for the program overall as well as for vulnerable subgroups. To interpret the HOS as a quality measure individual-and plan-level differences in functional status and illness burden, as well as methodologic issues in health status measurement, need to be recognized and addressed.
Using both employer- and beneficiary-level data, we examined trends in employer-sponsored retiree health insurance and prospects for future coverage. We found that retiree health insurance has become less prevalent over the past decade, with firms reporting declines in the availability of coverage, and Medicare-eligible retirees reporting lower rates of enrollment. The future of retiree health insurance is uncertain. The forces discouraging its growth--rising premium costs, a slower economy, judicial challenges, and an uncertain Medicare+Choice (M+C) program and policy agenda--far outweigh the forces likely to encourage expansion.
BACKGROUND: The clinical quality of health plans varies. The associations between different measures of health plan quality are incompletely understood. OBJECTIVE: To assess the relationships between enrollee reports on the quality of health plans as measured by the Consumer Assessment of Health Plans Study (CAHPS 2.0) survey and the clinical quality of care measured by the Medicare Health Plan Employer Data and Information Set (HEDIS). DESIGN: Observational cohort study. SAMPLE: National sample of 233 Medicare health plans that reported data using the CAHPS 2.0 survey and Medicare HEDIS during 1998. MEASURES: Five composite measures and four ratings derived from the CAHPS survey and six measures of clinical quality from Medicare HEDIS. RESULTS: Two composite measures ("getting needed care" and "health plan information and customer service") were significantly associated with most of the HEDIS clinical quality measures. The proportion of enrollees having a personal doctor was also significantly associated with rates of mammography, eye exams for diabetics, beta-blocker use after myocardial infarction, and follow-up after mental health hospitalization. Enrollees' ratings of health plan care were less consistently associated with HEDIS performance. In multivariable analyses, the measure of health plan communication ("health plan information and customer service") was the most consistent predictor of HEDIS performance. CONCLUSIONS: The pattern of associations we observed among some of the measures suggests that the CAHPS survey and HEDIS are complementary quality monitoring strategies. Our results suggest that health plans that provide better access and customer service also provide better clinical care.
A disproportionate share of the Medicare beneficiaries who lost coverage as a result of recent health maintenance organization (HMO) withdrawals have been from rural areas. Rural beneficiaries are less likely than urban beneficiaries are to have another Medicare+Choice (M+C) option. We surveyed a nationwide random sample of 1,093 rural beneficiaries to assess the impact of HMO withdrawals. A high proportion of beneficiaries ended up without any coverage beyond traditional Medicare; on average, beneficiaries experienced significant increases in premiums; and the proportion of beneficiaries with prescription drug coverage decreased significantly. These results raise questions about whether the federal government should encourage plans to enter rural markets where they will be the only M+C plan and where their withdrawal could have negative consequences for enrollees who lose coverage.
This final rule with comment period responds to comments on the June 26, 1998 interim final rule that implemented the Medicare+Choice (M+C) program and makes revisions to those regulations where warranted. We also are making revisions to the regulations that are necessary to reflect the changes to the M+C program resulting from the Balanced Budget Refinement Act of 1999 (BBRA). Revisions to the regulations reflecting changes in the law made by the BBRA are subject to public comment. Issues discussed in this rule include eligibility, election, and enrollment policies; marketing requirements; access requirements; service area and benefit policy; quality improvement standards; payment rates, risk adjustment methodology, and encounter data submission; provider participation rules; beneficiary appeals and grievances; contractual requirements; and preemption of State law by Federal law. This final rule also addresses comments on the interim final rule published on December 2, 1997, which implemented user fees for section 1876 risk contractors for 1998, and formed the basis for the M+C user fee provisions in the June 26, 1998 interim final rule, and the provider-sponsored organization (PSO) interim final rule published April 14, 1998.
CONTEXT: Substantial racial disparities in the use of some health services exist; however, much less is known about racial disparities in the quality of care. OBJECTIVE: To assess racial disparities in the quality of care for enrollees in Medicare managed care health plans. DESIGN AND SETTING: Observational study, using the 1998 Health Plan Employer Data and Information Set (HEDIS), which summarized performance in calendar year 1997 for 4 measures of quality of care (breast cancer screening, eye examinations for patients with diabetes, beta-blocker use after myocardial infarction, and follow-up after hospitalization for mental illness). PARTICIPANTS: A total of 305 574 (7.7%) beneficiaries who were enrolled in Medicare managed care health plans had data for at least 1 of the 4 HEDIS measures and were aged 65 years or older. MAIN OUTCOME MEASURES: Rates of breast cancer screening, eye examinations for patients with diabetes, beta-blocker use after myocardial infarction, and follow-up after hospitalization for mental illness. RESULTS: Blacks were less likely than whites to receive breast cancer screening (62.9% vs 70.9%; P<.001), eye examinations for patients with diabetes (43.6% vs 50.4%; P =.02), beta-blocker medication after myocardial infarction (64.1% vs 73.8%; P<.005), and follow-up after hospitalization for mental illness (33.2 vs 54.0%; P<.001). After adjustment for potential confounding factors, racial disparities were still statistically significant for eye examinations for patients with diabetes, beta-blocker use after myocardial infarction, and follow-up after hospitalization for mental illness. CONCLUSION: Among Medicare beneficiaries enrolled in managed care health plans, blacks received poorer quality of care than whites.
OBJECTIVE: To estimate the effect of Medicare+Choice (M+C) plan premiums and benefits and individual beneficiary characteristics on the probability of enrollment in a Medicare+Choice plan. DATA SOURCE: Individual data from the Medicare Current Beneficiary Survey were combined with plan-level data from Medicare Compare. STUDY DESIGN: Health plan choices, including the Medicare+Choice/Fee-for-Service decision and the choice of plan within the M+C sector, were modeled using limited information maximum likelihood nested logit. PRINCIPAL FINDINGS: Premiums have a significant effect on plan selection, with an estimated out-of-pocket premium elasticity of -0.134 and an insurer-perspective elasticity of -4.57. Beneficiaries are responsive to plan characteristics, with prescription drug benefits having the largest marginal effect. Sicker beneficiaries were more likely to choose plans with drug benefits and diabetics were more likely to pick plans with vision coverage. CONCLUSIONS: Plan characteristics significantly impact beneficiaries' decisions to enroll in Medicare M+C plans and individuals sort themselves systematically into plans based on individual characteristics.
We estimate the relation between enhanced benefits offered by the Medicare+Choice (M+C) plan in 1999 and a measure of risk selection based on inpatient encounter data. Higher risks are attracted to plans that offer outpatient drug coverage. The risk score increases by 2.2 percent for drug coverage with an annual limit less than $800 and by 3.6 percent for coverage with a limit more than $800. However, some benefits such as dental coverage were related to favorable risk selection. If M+C plans competed on the basis of benefits and premiums, as they would if they could give untaxed premium rebates, benefits that attract high risks would be underprovided.