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PubMed2002

Uncovering value in the Medicare+Choice marketplace.

Medicare managed care plans, now known as Medicare+Choice plans, have long been seen as a solution to Medicare's fiscal problems, including serving as a model for overall Medicare reform. Despite the challenges faced today, the M+C program provides a clear opportunity for the federal government to seek private innovation and experience in evolving Medicare to a more sustainable economic model, and for the private sector to tap into the vast product opportunities of serving a growing Medicare population.

Aged↗
PubMed2000

Principal inpatient diagnostic cost group model for Medicare risk adjustment.

The Balanced Budget Act (BBA) of 1997 required HCFA to implement health-status-based risk adjustment for Medicare capitation payments for managed care plans by January 1, 2000. In support of this mandate, HCFA has been collecting inpatient encounter data from health plans since 1997. These data include diagnoses and other information that can be used to identify chronic medical problems that contribute to higher costs, so that health plans can be paid more when they care for sicker patients. In this article, the authors describe the risk-adjustment model HCFA is implementing in the year 2000, known as the Principal Inpatient Diagnostic Cost Group (PIPDCG) model.

Adolescent↗
PubMed2003

Incidence and preventability of adverse drug events among older persons in the ambulatory setting.

CONTEXT: Adverse drug events, especially those that may be preventable, are among the most serious concerns about medication use in older persons cared for in the ambulatory clinical setting. OBJECTIVE: To assess the incidence and preventability of adverse drug events among older persons in the ambulatory clinical setting. DESIGN, SETTING, AND PATIENTS: Cohort study of all Medicare enrollees (30 397 person-years of observation) cared for by a multispecialty group practice during a 12-month study period (July 1, 1999, through June 30, 2000), in which possible drug-related incidents occurring in the ambulatory clinical setting were detected using multiple methods, including reports from health care providers; review of hospital discharge summaries; review of emergency department notes; computer-generated signals; automated free-text review of electronic clinic notes; and review of administrative incident reports concerning medication errors. MAIN OUTCOME MEASURES: Number of adverse drug events, severity of the events (classified as significant, serious, life-threatening, or fatal), and whether the events were preventable. RESULTS: There were 1523 identified adverse drug events, of which 27.6% (421) were considered preventable. The overall rate of adverse drug events was 50.1 per 1000 person-years, with a rate of 13.8 preventable adverse drug events per 1000 person-years. Of the adverse drug events, 578 (38.0%) were categorized as serious, life-threatening, or fatal; 244 (42.2%) of these more severe events were deemed preventable compared with 177 (18.7%) of the 945 significant adverse drug events. Errors associated with preventable adverse drug events occurred most often at the stages of prescribing (n = 246, 58.4%) and monitoring (n = 256, 60.8%), and errors involving patient adherence (n = 89, 21.1%) also were common. Cardiovascular medications (24.5%), followed by diuretics (22.1%), nonopioid analgesics (15.4%), hypoglycemics (10.9%), and anticoagulants (10.2%) were the most common medication categories associated with preventable adverse drug events. Electrolyte/renal (26.6%), gastrointestinal tract (21.1%), hemorrhagic (15.9%), metabolic/endocrine (13.8%), and neuropsychiatric (8.6%) events were the most common types of preventable adverse drug events. CONCLUSIONS: Adverse drug events are common and often preventable among older persons in the ambulatory clinical setting. More serious adverse drug events are more likely to be preventable. Prevention strategies should target the prescribing and monitoring stages of pharmaceutical care. Interventions focused on improving patient adherence with prescribed regimens and monitoring of prescribed medications also may be beneficial.

Adverse Drug Reaction Reporting Systems↗
PubMed2001

HMO provider networks in Medicare+Choice: comparing Medicare and commercial lines of business.

The Medicare+Choice (M+C) program was intended to expand choice of managed care plans for Medicare beneficiaries. In the past few years, the opposite has occurred as many participating HMOs reduced Medicare service areas or withdrew from the program. This paper presents findings from a study of the provider networks of 85 HMOs that were participating in M+C in 1999. The study shows that provider networks serving Medicare enrollees are usually similar to those developed for HMOs' commercial line of business, but when they are different, Medicare provider networks are smaller. Most HMOs also had at least some problems maintaining their Medicare provider networks. These findings have implications for the future of the Medicare+Choice program and Medicare enrollees' access to health care.

Aged↗
PubMed2001

Medicare+Choice: doubling or disappearing?

Although the changes in the program created by the Balanced Budget Act are often viewed as the reason for the current instability in the Medicare+Choice (M+C) program, in fact, health plans are having difficulties in all of their markets, not just in Medicare. It may be time to reconsider the purpose of the program and to fundamentally redesign how payments are made to managed care organizations contracting with Medicare. Two alternative approaches are suggested: treating M+C like another provider type by severing the payment linkage to spending under traditional Medicare, and overhauling the program by creating a value-based purchasing orientation rewarding plans that provide higher-quality care to beneficiaries with chronic diseases.

Aged↗
PubMed2004

Risk adjustment of Medicare capitation payments using the CMS-HCC model.

This article describes the CMS hierarchical condition categories (HCC) model implemented in 2004 to adjust Medicare capitation payments to private health care plans for the health expenditure risk of their enrollees. We explain the model's principles, elements, organization, calibration, and performance. Modifications to reduce plan data reporting burden and adaptations for disabled, institutionalized, newly enrolled, and secondary payer subpopulations are discussed.

Adolescent↗
PubMedDate not supplied

Can managed care and competition control Medicare costs?

Medicare+Choice (M+C) was conceived to bring managed care and competitive forces to bear on Medicare. Ultimately, M+C could not thrive under the conditions of the marketplace and the Balanced Budget Act of 1997. Here I review what went wrong and the lessons from the experience, concluding that M+C is a tool, not a strategy. While managed care in a multiple-choice environment may have the potential to generate limited savings, promoting managed care and competition alone will not preempt the need for a debate on Medicare's obligations and how to finance them.

Aged↗
PubMedDate not supplied

Medicare advantage: déjà vu all over again?

The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 expands the role of private health plans in Medicare through prescription drug plans and a revised Medicare+Choice (M+C), renamed Medicare Advantage, program. This paper discusses the factors responsible for the failure of M+C to develop as intended in 1997 and analyzes the challenges for MMA implementation in light of these factors. They include making a complex program understandable to beneficiaries; addressing plans' efforts to avoid enrolling high-cost beneficiaries; ensuring stability of benefits, providers, and plans; dealing with beneficiaries enrolled in unsuitable plans; providing equity of health benefits throughout the country; and controlling overall Medicare costs.

Aged↗
PubMed2001

Reforming Medicare: impacts on federal spending and choice of health plans.

The rising cost of Medicare and well-documented problems plaguing Medicare+Choice (M+C) have increased interest in "reforming" the program. To improve efficiency, most reform proposals would rely on competitive bidding to establish payments to M+C plans. At the same time, beneficiaries would be given financial incentives to select low-cost M+C plans. A major unknown is the extent to which Medicare reforms would generate federal budgetary savings. To examine this issue, we develop three illustrative Medicare reform options that differ greatly in how Medicare would establish its payments to plans. Our results highlight the fact that Medicare should expect modest savings from reforming the program. However, other goals of reform, such as establishing more efficient payments to plans, would be achieved.

Aged↗
PubMed2001

Premium rebates and the quiet consensus on market reform for Medicare.

Premium rebates allow beneficiaries who choose more efficient Medicare options to receive cash rebates, rather than extra benefits. That simple idea has been controversial. Without fanfare, however, premium rebates have become a key area of agreement in the debate on Medicare reform. Moreover, in legislation in late 2000, it became official policy: Medicare+Choice (M+C) plans will be allowed to offer rebates beginning in 2003. This article explores the economic rationale for premium rebates, provides a historical perspective on the rebate debate, discusses some of the implementation issues that need to be addressed before 2003, and reviews the implications of premium rebates for current legislative proposals for Medicare reform.

Aged↗
PubMedDate not supplied

A tale of four cities: Medicare reform and competitive pricing.

The current payment system for Medicare + Choice (M + C) plans is based on prices calculated from administrative records. This system has been criticized as arbitrary, inefficient, and unfair. Most Medicare reform proposals would replace the current payment system with some form of competitive pricing. However, efforts over the past five years to demonstrate competitive pricing for M + C plans have been blocked repeatedly by Congress, even when the demonstrations were directly responsive to a congressional mandate. In the absence of political support, a demonstration of competitive pricing may be infeasible, and Congress could be forced to take the risky step of implementing broad Medicare reforms with very little information about their effects.

Arizona↗
PubMed2003

An analysis of availability of Medicare+Choice, commercial HMO, and FEHBP plans in rural areas: implications for Medicare reform.

This Policy Brief examines the viability of introducing private competition into the Medicare program by studying the availability of Medicare+Choice (M+C), commercial HMO, and Federal Employees Health Benefits Program (FEHBP) plans in rural (nonmetropolitan) counties. The Brief also presents evidence regarding the variables that influence plan availability and impact plan choice across counties in the U.S. The findings in this Brief will be useful to policymakers considering using a competitive model to design a Medicare prescription drug benefit or to redesign the entire Medicare program. As changes in the Medicare program are considered, the information in this Brief will provide background regarding rural participation in earlier Medicare program changes and in other programs said to be models for change.

Economic Competition↗
PubMed2003

Developing Medicare HMO market areas and their implications for HMO capitation rates.

Medicare+Choice (M+C) rates have replaced the average adjusted per-capita cost (AAPCC) payment method to HMOs as a result of the use of disparate benefit packages. However, the creation of M+C rates has likely caused HMOs to withdraw from the program. The underlying AAPCC problems are argued herein to be statistical in nature and arise because the AAPCC rates have been calculated on a county basis, although the county is generally not a health care market area. The author provides a method for empirically defining empirical market areas (EMAs), key principles to which one should adhere in developing these EMAs, and evidence that EMAs can serve as health care market areas.

Aged↗
PubMed2003

The welfare impact of Medicare HMOs.

We estimate the welfare associated with the Medicare HMO program, now known as Medicare+Choice (M+C). We find that the creation of the M+C program resulted in approximately $15.6 billion in consumer surplus and $52 billion in profits from 1993 to 2000 (in 2000 dollars). This program most likely generated significant net social welfare. However, we find that consumer surplus is geographically unevenly distributed. Prescription drug coverage accounts for approximately 45% of the estimated consumer surplus for 2000. Consumer surplus increases in the number of plans in a county, and most of the increase in welfare is due to increased premium competition.

Health Expenditures↗
PubMed2002

Payment policy and competition in the Medicare+Choice program.

Over the last 2 years, Medicare+Choice (M+C) plans raised premiums and reduced benefits to an unprecedented degree, arguing that these were unavoidable consequences of inadequate payments. We investigate plan premium and benefit decisions, taking advantage of a natural experiment to separate the influences of payment rates, the intensity of interplan competition, and the underlying cost of providing coverage. We find that the effects of competition are comparable in importance to the effects of payment rates, confirming empirically that it is possible for the Medicare Program to improve benefits without increasing spending or shifting additional costs to beneficiaries.

Aged↗
PubMed2002

Managed care and dually eligible beneficiaries: challenges in coordination.

This article describes administrative issues and beneficiary perspectives on the delivery of medical services under Medicare+Choice (M+C) and/or Medicaid managed care organizations (MCOs) for dually eligible beneficiaries. We interviewed staff at nine health plans in four market areas in 2000 and 2001, and conducted beneficiary focus groups in 2001. The study reveals beneficiary confusion about the relationship between their dual coverage and managed care enrollment, and problems with care and benefit coordination across these arrangements, based on regulatory and administrative obstacles to effective benefit and care coordination for beneficiaries enrolled in these varied managed care arrangements.

Case Management↗
PubMed2003

The effect of health plan characteristics on Medicare+ Choice enrollment.

OBJECTIVE: To provide national estimates of the effect of out-of-pocket premiums and benefits on Medicare beneficiaries' choice among managed care health plans. DATA SOURCES/STUDY SETTING: The data represent the population of all Medicare+ Choice (M+C) plans offered to Medicare beneficiaries in the United States in 1999. STUDY DESIGN: The dependent variable is the log of the ratio of the market share of the jth health plan to the lowest cost plan in the beneficiary's county of residence. The explanatory variables are measures of premiums and benefits in the jth health plan relative to the premiums and benefits in the lowest cost plan. DATA COLLECTION METHODS: The data are from the 1999 Medicare Compare database, and M+C enrollment data from the Centers for Medicare and Medicaid Services (CMS). PRINCIPAL FINDINGS: A $10 increase in an M+C plan's out-of-pocket premium, relative to its competitors, is associated with a decrease of four percentage points in the jth plan's market share (i.e., from 25 to 21 percent), holding the premiums of competing plans constant. CONCLUSIONS: Although our price elasticity estimates are low, the market share losses associated with small changes in a health plan's premium, relative to its competitors, may be sufficient to discipline premiums in a competitive market. Bidding behavior by plans in the Medicare Competitive Pricing Demonstration supports this conclusion.

Aged↗
PubMed2004

Does Medicare managed care provide equal treatment for mental illness across races?

BACKGROUND: While disparities in access to care are well documented, little is known about the quality of mental health care received by racial and ethnic minorities. We examined the quality of mental health care received by elderly enrollees in Medicare + Choice plans. METHODS: An observational study was performed using individual-level Health Plan Employer Data and Information Set data. From 4182 to 5,016,028 individuals 65 years or older and enrolled in Medicare + Choice plans in 1999 were involved in different measures. Rates of mental health inpatient discharges, average length of stay, percentage of members receiving mental health services, rates of follow-up after hospitalization for mental illness, optimal practitioner contacts for antidepressant medication management, and effective acute- and continuation-phase treatment were assessed. RESULTS: Compared with whites, minorities received substantially less follow-up after hospitalization for mental illness. The 30-day follow-up rates for whites, African Americans, Asians, and Hispanics were 60.2%, 42.4%, 54.1%, and 52.6%, respectively. Minorities also had lower rates of antidepressant medication management for newly diagnosed episodes of depression. The rates of optimal practitioner contacts for whites, African Americans, Asians, and Hispanics were 12.5%, 12.0%, 11.1%, and 10.6%; the rates of effective acute-phase treatment were 60.1%, 48.5%, 40.7%, and 57.6%; and the rates of effective continuation-phase treatment were 46.7%, 32.7%, 31.9%, and 39.6%, respectively. The statistically significant disparities persisted after adjusting for effects of age, sex, income, plan model, profit status, and region of the country. CONCLUSIONS: The overall quality of mental health care for people enrolled in Medicare + Choice managed care plans is far from optimal. There are large and persistent racial differences that merit further attention to better understand their underlying causes and solutions.

Aged↗