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PubMed2001

Influenza vaccination, hospitalizations, and costs among members of a Medicare managed care plan.

OBJECTIVE: To evaluate the effectiveness and possible cost savings of influenza vaccination. SUBJECTS: Members age 65 and older in a Medicare managed care plan during the 1994-1995, 1995-1996, and 1996-1997 influenza seasons. RESEARCH DESIGN: The study examined administrative data on influenza vaccination and subsequent hospitalizations. Outcomes included hospitalization with pneumonia or influenza, with any respiratory condition, and with congestive heart failure (CHF). RESULTS: Vaccinated subjects experienced fewer hospitalizations with respiratory conditions or CHF than had unvaccinated subjects (OR=0.8 (95% CI, 0.7, 0.9) in analyses adjusted for age, sex, pneumococcal vaccination, health utilization, and morbidity). Analyses adjusted in addition for ethnicity obtained similar results among the subgroup of members whose ethnicity was known. Subjects without major disease in the previous 12 months had lower odds ratios for vaccination than subjects with major disease (OR values of 0.5 [95% CI, 0.4, 0.7] and 0.9 [95% CI, 0.8, 1.1], respectively). Subjects ages 65 to 79 had lower odds ratios for vaccination than subjects ages 80 and older (OR values of 0.7 [95% CI, 0.6, 0.9] and 0.9 [95% CI, 0.8, 1.1], respectively). Estimated cost savings averaged about $80 per vaccinated subject. CONCLUSIONS: Subjects ages 65 to 79 who had received influenza vaccination experienced fewer hospitalizations and had lower costs than had unvaccinated subjects. Associations were weaker for subjects age 80 and older. The results, consistent with recommendations for the use of influenza vaccine, suggest that people ages 65 to 79 should be heavily targeted for vaccination.

Acute Disease↗
PubMed2004

Prescription drug coverage, health, and medication acquisition among seniors with one or more chronic conditions.

BACKGROUND: The unabated rise in medication costs particularly affects older persons with chronic conditions that require long-term medication use, but how prescription benefits affect medication adherence for such persons has received limited study. OBJECTIVE: We sought to study the relationship among prescription benefit status, health, and medication acquisition in a sample of elderly HMO enrollees with 1 or more common, chronic conditions. RESEARCH DESIGN: We implemented a cross-sectional cohort study using primary survey data collected in 2000 and administrative data from the previous 2 years. SUBJECTS: Subjects were aged 67 years of age and older, continuously enrolled in a Medicare + Choice program for at least 2 years, and diagnosed with 1 or more of hypertension, diabetes, congestive heart failure, and coronary artery disease (n = 3073). MEASURES: Outcomes were the mean daily number of essential therapeutic drug classes and refill adherence. RESULTS: In multivariate models, persons without a prescription benefit acquired medications in 0.15 fewer therapeutic classes daily and experienced lower refill adherence (approximately 7 fewer days of necessary medications during the course of 2 years) than those with a prescription benefit. A significant interaction revealed that, among those without a benefit, persons in poor health acquired medications in 0.73 more therapeutic classes daily than persons in excellent health; health status did not significantly influence medication acquisition for those with a benefit. CONCLUSIONS: Coverage of prescription drugs is important for improving access to essential medications for persons with the studied chronic conditions. A Medicare drug benefit that provides unimpeded access to medications needed to treat such conditions may improve medication acquisition and, ultimately, health.

Aged↗
PubMed2002

Health care reform and the pharmaceutical industry: crucial decisions are expected.

For the past 30 years, the largest growing segment of the United States economy is the health care industry. The United States is in a transitional period as American citizens born between 1946 and 1964, the Baby Boomer generation, reach retirement age. In recent years, pharmaceutical costs have been rising faster than the inflation rate, leaving the American public to ask many questions. A major area of interest to policymakers regarding the health care reform agenda is patient spending on pharmaceutical items. Government-funded programs such as Medicare and Medicaid are facing the possibility of running out of funds and require substantive reform. Pharmaceuticals are not covered under the basic Medicare programs. As a result, senior citizens are forced to cover their prescription expenses out of pocket or purchase supplemental insurance plans. This extra expense is leaving many senior citizens across the country struggling to support their ongoing medical needs.

Advertising↗
PubMed2002

The impact of the Balanced Budget Act of 1997 on Medicare in the USA: the fallout continues.

Although the United States Congress has attempted to ameliorate some of the adverse impacts of the Balanced Budget Act through the 1999 Balanced Budget Refinement Act, the final results of the reforms to Medicare remain to be seen. This article provides an update and examines the impacts of the Balanced Budget Act on health providers and medical education. The authors also discuss the implications of these impacts for further policy adjustment.

Aged↗
PubMed2003

Utilization of home health services before and after the Balanced Budget Act of 1997: what were the initial effects?

OBJECTIVE: To estimate the impact of the Balanced Budget Act of 1997 (BBA), which changed the way Medicare reimbursed for home health services, on a range of home health utilization measures, and to examine whether particular subgroups of beneficiaries were differentially impacted in the post-BBA period. DATA SOURCES: Secondary data from the Centers for Medicare and Medicaid Services (CMS) Standard Analytic Files for the 1 percent sample of Medicare beneficiaries for fiscal years 1997 and 1999, linked with information from CMS eligibility, provider, and cost report files as well as the Area Resources File. STUDY DESIGN: Logistic regression was used to estimate the effects of being in the post-BBA period on the incidence of home health service use and ordinary least squares (OLS) regression was used to estimate the effects of being in the post-BBA period on the amount and type of use by home health service users. Interaction terms we reincluded for all the independent variables to assess whether the effect was disproportionate among particular beneficiary subgroups. PRINCIPAL FINDINGS: Results show a 22 percent decrease in the percentage using home health services post-BBA and a 39 percent decrease in the number of visits per user. Stronger reductions, though not very large, were found in the incidence of use for beneficiaries aged 85 and older, those in states with high historical Medicare home health use, and those with Medicaid buy-in. More intensive reductions in the number of services were found for those aged 85 and older, in high historical Medicare use states, nonwhites, females, those using for-profit agencies, and those treated for certain diagnoses. Less intensive reductions were associated with hospital-based agencies. CONCLUSIONS: This research demonstrates that public program expenditures can be sharply curtailed with financial incentives. As reimbursement shifts to a prospective payment system legislated by the BBA, utilization should be closely monitored, especially for vulnerable subgroups.

Aged↗
PubMed2002

Medigap premiums and Medicare HMO enrollment.

OBJECTIVE: Markets for Medicare HMOs (health maintenance organizations) and supplemental Medicare coverage are often treated separately in existing literature. Yet because managed care plans and Medigap plans both cover services not covered by basic Medicare, these markets are clearly interrelated. We examine the extent to which Medigap premiums affect the likelihood of the elderly joining managed care plans. DATA SOURCES: The analysis is based on a sample of Medicare beneficiaries drawn from the 1996-1997 Community Tracking Study (CTS) Household Survey by the Center for Studying Health System Change. Respondents span 56 different CTS sites from 30 different states. Measures of premiums for privately-purchased Medigap policies were collected from a survey of large insurers serving this market. Data for individual, market, and HMO characteristics were collected from the CTS, InterStudy, and HCFA (Health Care Financing Administration). STUDY DESIGN: Our analysis uses a reduced-form logit model to estimate the probability of Medicare HMO participation as a function of Medigap premiums controlling for other market- and individual-level characteristics. The logit coefficients were then used to simulate changes in Medicare participation in response to changes in Medigap premiums. PRINCIPAL FINDINGS: We found that Medigap premiums vary considerably among the geographic markets included in our sample. Measures of premiums from different insurers and for different types of Medigap policies were generally highly correlated across markets. Our models consistently indicate a strong positive relationship between Medigap premiums and HMO participation. This result is robust across several specifications. Simulations suggest that a one standard deviation increase in Medigap premiums would increase HMO participation by more than 8 percentage points. CONCLUSIONS: This research provides strong evidence that Medigap premiums have a significant effect on seniors' participation in Medicare HMOs. Policy initiatives aimed at lowering Medigap premiums will likely discourage enrollment in Medicare HMOs, holding other factors constant. Although the Medigap premiums are just one factor affecting the future penetration rate of Medicare HMOs, they are an important driver of HMO enrollment and should be considered carefully when creating policy related to seniors' supplemental coverage. Similarly, our results imply that reforms to the Medicare HMO market would influence the demand for Medigap policies.

Aged↗
PubMed2004

The costs of decedents in the Medicare program: implications for payments to Medicare + Choice plans.

OBJECTIVE: To discuss and quantify the incentives that Medicare managed care plans have to avoid (through selective enrollment or disenrollment) people who are at risk for very high costs, focusing on Medicare beneficiaries in the last year of life-a group that accounts for more than one-quarter of Medicare's annual expenditures. DATA SOURCE: Medicare administrative claims for 1994 and 1995. STUDY DESIGN: We calculated the payment a plan would have received under three risk-adjustment systems for each beneficiary in our 1995 sample based on his or her age, gender, county of residence, original reason for Medicare entitlement, and principal inpatient diagnoses received during any hospital stays in 1994. We compared these amounts to the actual costs incurred by those beneficiaries. We then looked for clinical categories that were predictive of costs, including costs in a beneficiary's last year of life, not accounted for by the risk adjusters. DATA EXTRACTION METHODS: The analyses were conducted using claims for a 5 percent random sample of Medicare beneficiaries who died in 1995 and a matched group of survivors. PRINCIPAL FINDINGS: Medicare is currently implementing the Principal Inpatient Diagnostic Cost Groups (PIP-DCG) risk adjustment payment system to address the problem of risk selection in the Medicare+Choice program. We quantify the strong financial disincentives to enroll terminally ill beneficiaries that plans still have under this risk adjustment system. We also show that up to one-third of the selection observed between Medicare HMOs and the traditional fee-for-service system could be due to differential enrollment of decedents. A risk adjustment system that incorporated more of the available diagnostic information would attenuate this disincentive; however, plans could still use clinical information (not included in the risk adjustment scheme) to identify beneficiaries whose expected costs exceed expected payments. CONCLUSIONS: More disaggregated prospective risk adjustment methods and alternative payment systems that compensate plans for delivering care to certain classes of patients should be considered to ensure access to high-quality managed care for all beneficiaries.

Actuarial Analysis↗
PubMed2004

Specificity and sensitivity of claims-based algorithms for identifying members of Medicare+Choice health plans that have chronic medical conditions.

OBJECTIVE: To examine the effects of varying diagnostic and pharmaceutical criteria on the performance of claims-based algorithms for identifying beneficiaries with hypertension, heart failure, chronic lung disease, arthritis, glaucoma, and diabetes. STUDY SETTING: Secondary 1999-2000 data from two Medicare+Choice health plans. STUDY DESIGN: Retrospective analysis of algorithm specificity and sensitivity. DATA COLLECTION: Physician, facility, and pharmacy claims data were extracted from electronic records for a sample of 3,633 continuously enrolled beneficiaries who responded to an independent survey that included questions about chronic diseases. PRINCIPAL FINDINGS: Compared to an algorithm that required a single medical claim in a one-year period that listed the diagnosis, either requiring that the diagnosis be listed on two separate claims or that the diagnosis to be listed on one claim for a face-to-face encounter with a health care provider significantly increased specificity for the conditions studied by 0.03 to 0.11. Specificity of algorithms was significantly improved by 0.03 to 0.17 when both a medical claim with a diagnosis and a pharmacy claim for a medication commonly used to treat the condition were required. Sensitivity improved significantly by 0.01 to 0.20 when the algorithm relied on a medical claim with a diagnosis or a pharmacy claim, and by 0.05 to 0.17 when two years rather than one year of claims data were analyzed. Algorithms that had specificity more than 0.95 were found for all six conditions. Sensitivity above 0.90 was not achieved all conditions. CONCLUSIONS: Varying claims criteria improved the performance of case-finding algorithms for six chronic conditions. Highly specific, and sometimes sensitive, algorithms for identifying members of health plans with several chronic conditions can be developed using claims data.

Algorithms↗
PubMed2006

Will choice-based reform work for Medicare? Evidence from the Federal Employees Health Benefits Program.

OBJECTIVE: . To examine the effect of premiums and benefits on the health plan choices of older enrollees who choose Federal Employees Health Benefits Program (FEHBP) health plans as their primary payer. DATA SOURCES: Administrative enrollment data from the Office of Personnel Management (OPM) and plan premiums and benefits data taken from the Checkbook Guide to health plans. STUDY DESIGN: We estimate individual plan choice models where the choice of health plan is a function of out-of-pocket premium, actuarial value, plan attributes, and individual characteristics. Plan attributes include plan structure (fee-for-service/preferred provider organization, point-of-service, or health maintenance organization), drug benefit structure, and whether or not the plan covers other types of spending such as dental services and diabetic supplies. The models are estimated by conditional logit. Our study focuses on three populations that currently choose FEHBP as their primary health care coverage and are similar to the Medicare population: current employees and retirees who are approaching the age of Medicare eligibility (ages 60-64) and current federal employees age 65+. Current employees age 65+ are eligible for Medicare, but their FEHBP plan is their primary payer. Retirees and employees 60-64 are not yet eligible for Medicare but are similar in many respects to recently age-eligible Medicare beneficiaries. We also estimate our model for current employees age 55 and younger as a comparison group. DATA COLLECTION METHODS: We select a random sample of retirees and employees age 60-64, as well as all current employees age 65+, from the OPM administrative database for the calendar year 2001. The plan choices available to each person are determined by the plans participating in their metropolitan statistical area. We match plan premium and attribute information from the Checkbook Guide to each plan in the enrollee's list of choices. PRINCIPAL FINDINGS: We find that current workers 65+, 60-64, and non-Medicare eligible retirees are sensitive to variation in plan premiums. The premium elasticities for these groups are similar in magnitude to those of the age 55 and under employee group. Older workers and retirees not yet eligible for Medicare are willing to pay a substantial amount for plans with open provider networks. The willingness to pay for open networks is significantly greater for these groups than for younger employees. Willingness to pay for open network plans varies significantly by income, but varies little by age within group. CONCLUSIONS: Our finding that older workers and non-Medicare eligible retirees are sensitive to plan premiums suggests that choice-based reform of Medicare would lead to cost-conscious choices by Medicare beneficiaries. However, our finding that these groups are willing to pay more for open network plans than younger employees suggest that higher risk individuals may migrate toward higher benefit, higher cost plans. Our findings on the relationship between income and willingness to pay for open network plans suggest that means testing is a viable reform for lowering Medicare program costs.

Adult↗
PubMedDate not supplied

Seniors with chronic health conditions and prescription drugs: benefits, wealth, and health.

OBJECTIVES: The objectives of this study were to examine the relationship between prescription benefit status and access to medications among Medicare beneficiaries with hypertension, congestive heart failure, coronary artery disease, and diabetes and to determine how income, wealth, and health status influence this relationship. METHODS: We analyzed survey and administrative data for 4492 Medicare + Choice enrollees aged 67 and above enrolled in a predominantly group-model health maintenance organization in 2000. Outcome measures included difficulty affording medications, methods of coping with medication costs including obtaining medicines from another country, using free samples, and stretching out medications to make them last longer. Independent variables included prescription benefit status, income, wealth measures, health status, and out-of-pocket prescription drug spending. RESULTS: Lacking a prescription benefit was independently associated with difficulty affording medications (25% of those without a benefit vs. 17% with a benefit) and coping methods such as stretching out medications. Lower income, lower assets, and worse health status also independently predicted greater difficulty as measured by these outcomes; there was no effect modification between these factors and benefit status. Relative to national figures, out-of-pocket spending in this setting was quite low, with only 0.2 and 13% of those with and without a benefit, respectively, spending over 100 dollars per month. Higher out-of-pocket spending predicted greater difficulty affording medications but not stretching out medications. CONCLUSIONS: Efforts to improve medication accessibility for older Americans with chronic conditions need to address not only insurance coverage but also barriers related to socioeconomic status and health status.

Aged↗
PubMed1999

Tracking the response to the Balanced Budget Act of 1997: impact on Medicare managed care enrollment in rural counties.

The impact of the Balanced Budget Act of 1997 on recent changes in enrollment of Medicare beneficiaries into managed care plans is examined. The Balanced Budget Act of 1997 created a new payment structure for Medicare risk contracts, which, in 1998, resulted in all counties receiving either a minimum payment or a payment with the increase restricted at 2 percent growth over the 1997 rate. Using a baseline of December 1997 and enrollment data through June 1998, differences in early enrollment trends between urban and rural counties and between counties at various rates of payment are examined. As expected, continued enrollment increases in all counties is observed but with some concerns about slow enrollment growth--and announcements of plan terminations--in counties with payment rates in the mid-range, above the floor payment but subject to the 2 percent growth. In addition, evidence of considerable changes in the benefits offered by plans and the premiums charged to beneficiaries also was observed during the first nine months of 1998. The implications for growth of managed care options in rural areas are still unclear. The floor on payments may be helpful, but constraints in payment increases and delays in implementing a blended rate can be expected to create a negative impact on decisions to market managed care plans.

Budgets↗
PubMed2000

Quality-of-care challenges for rural health.

The purpose of this article is to examine the issue of quality of care in rural America and to help others examine this issue in a way that is consistent with the very real challenges faced by rural communities in ensuring the availability of adequate health services. Rural citizens have a right to expect that their local health care meets certain basic standards. Unless rural providers can document that the quality of local health care meets objective external standards, third-party payers might refuse to contract with rural providers, and increasingly sophisticated consumers might leave their communities for basic medical care services. To improve the measurement of health care quality in a rural setting, a number of issues specific to the rural environment must be addressed, including small sample sizes (volume and outcome issues), limited data availability, the ability to define rural health service areas, rural population preferences and the lower priority of formal quality-of-care assessment in shortage areas. Several current health policy initiatives have substantial implications for monitoring and measuring the quality of rural health services. For example, to receive community acceptance and achieve fiscal stability, critical access hospitals (CAHs) must be able to document that the care they provide is at least comparable to that of their predecessor institutions. The expectations for quality assurance activities in CAHs should consider their limited institutional resources and community preferences. As managed care extends from urban areas, there will be an inevitable collision between the ability to provide care and the ability to measure quality. As desirable as it might be to have a national standard for health care quality, this is not an attainable goal. The spectrum and content of rural health care are different from the spectrum and content of care provided in large cities. Accrediting agencies, third-party carriers and health insurance purchasers need to develop rural health care quality standards that are practical, useful and affordable.

Health Services Accessibility↗
PubMed2002

Effect of medicare payment on rural health care systems.

Medicare payments constitute a significant share of patient-generated revenues for rural providers, more so than for urban providers. Therefore, Medicare payment policies influence the behavior of rural providers and determine their financial viability. Health services researchers need to contribute to the understanding of the implications of changes in fee-for-service payment policy, prospects for change because of the payment to Medicare+Choice risk plans, and implications for rural providers inherent in any restructuring of the Medicare program. This article outlines the basic policy choices, implications for rural providers and Medicare beneficiaries, impacts of existing research, and suggestions for further research. Topics for further research include implications of the Critical Access Hospital program, understanding how changes in payment to rural hospitals affect patient care, developing improved formulas for paying rural hospitals, determining the payment-to-cost ratio for physicians, measuring the impact of changes in the payment methodology used to pay for services delivered by rural health clinics and federally qualified health centers, accounting for the reasons for differences in historical Medicare expenditures across rural counties and between rural and urban counties, explicating all reasons for Medicare+Choice plans withdrawing from some rural areas and entering others, measuring the rural impact of proposals to add a prescription drug benefit to the Medicare program, and measuring the impact of Medicare payment policies on rural economies.

Aged↗
PubMedDate not supplied

Analysis of a large cohort of health maintenance organization patients with congestive heart failure.

The aim of this article was to measure guideline compliance in the care of health plan members diagnosed with congestive heart failure (CHF). Chart review was conducted on members with a discharge diagnosis of CHF (n = 2,697). Information was entered onto a scannable form designed by the health plan, which was coupled to an optical character recognition reader and entered into a database. Eighty-four percent of the patients had an ejection fraction (EF) measured. An angiotensin-converting enzyme inhibitor was prescribed to 72% of patients with an EF less than 40%. Comorbidities and other measures were evaluated and based on guideline recommendations. Most of the CHF patients in this health plan are being treated appropriately during posthospitalization for CHF. The use of a novel, cost-effective method for data collection resulted in the rapid acquisition of clinical data for analysis.

Adult↗
PubMed2006

Do content and format affect older consumers' use of comparative information in a Medicare health plan choice? Results from a controlled experiment.

We assessed the efficacy of materials that integrated comparative information on cost, benefits, and quality for employer-based retiree health plans and Medicare Advantage plans in a randomized experiment to test the impact of content and format. Results indicate that older consumers who received the intervention materials found the materials easier to use, gained greater knowledge about Medicare from them, were more likely to value comparative quality information, were more likely to select higher quality plans, and were more likely to choose a plan that reflected the dimensions they found most important compared to older consumers receiving the control materials.

Choice Behavior↗
PubMed2004

The Medicare Health Outcomes Survey program: overview, context, and near-term prospects.

In 1996, the Centers for Medicare & Medicaid Services (CMS) initiated the Medicare Health Outcomes Survey (HOS). It is the first national survey to measure the quality of life and functional health status of Medicare beneficiaries enrolled in managed care. The program seeks to gather valid and reliable health status data in Medicare managed care for use in quality improvement activities, public reporting, plan accountability and improving health outcomes based on competition. The context that led to the development of the HOS was formed by the convergence of the following factors: 1) a recognized need to monitor the performance of managed care plans, 2) technical expertise and advancement in the areas of quality measurement and health outcomes assessment, 3) the existence of a tested functional health status assessment tool (SF-36)1, which was valid for an elderly population, 4) CMS leadership, and 5) political interest in quality improvement. Since 1998, there have been six baseline surveys and four follow up surveys. CMS, working with its partners, performs the following tasks as part of the HOS program: 1) Supports the technical/scientific development of the HOS measure, 2) Certifies survey vendors, 3) Collects Health Plan Employer Data and Information Set(HEDIS)2 HOS data, 4) Cleans, scores, and disseminates annual rounds of HOS data, public use files and reports to CMS, Quality Improvement Organizations (QIOs), Medicare+Choice Organizations (M+COs), and other stakeholders, 5) Trains M+COs and QIOs in the use of functional status measures and best practices for improving care, 6) Provides technical assistance to CMS, QIOs, M+COs and other data users, and 7) Conducts analyses using HOS data to support CMS and HHS priorities.CMS has recently sponsored an evaluation of the HOS program, which will provide the information necessary to enhance the future administration of the program. Information collected to date reveals that the HOS program is a valuable tool that provides a rich set of data that is useful for quality monitoring and improvement efforts. To enhance the future of the HOS program, many stakeholders recommend the implementation of incentives to encourage the use of the data, while others identify the need to monitor the health status of plan disenrollees.Overall, the HOS program represents an important vehicle for collecting outcomes data from Medicare beneficiaries. The new Medicare Prescription Drug, Improvement, and Modernization Act (2003) mandates the collection and use of data for outcomes measurement. Consequently, it is important to improve HOS to most effectively meet the mandate.

Activities of Daily Living↗