Improving the Medicare Market Adding Choice and Protections (1996) / Chapter Skim
Currently Skimming:
2 Symposium Summary
2 Symposium Summary
Pages 39-79
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 39... ...
A new paradigm is forming, however, in which efforts are being made to restructure the Medicare program around mar 1Unless otherwise noted, the material in this section is based on a presentation by Lynn Etheredge.
|
From page 40... ...
, unrestricted fee-for-service health plans, and highdeductible plans combined with medical savings accounts. Under the new paradigm most Medicare beneficiaries would have more health plan choices than the majority of today's privatesector employees (Table 2-1)
|
From page 41... ...
. This more inclusive purchaser approach may cause confusion among some beneficiaries, since they have had little experience with managed care plans and there is evidence that they may need assistance evaluating information.
|
From page 42... ...
Historically, government has not acted in this capacity. Strengthening the Role of Consumers Strengthening the role of consumers would require providing them with sufficient relevant information about health plans to help them decide whether to join a managed care plan and, if so, how to choose a plan that meets their needs.
|
From page 43... ...
Other options that might be considered and reflected in proposed legislation are requirements that health plans meet high government standards in order to be accredited organizations for participation as a Medicare health plan. Another option would be for Medicare to develop best-practice benchmarks and other management purchasing techniques that promote high standards for competing health care plans.
|
From page 44... ...
Patients as Consumers Evidence indicates that many among the elderly and disabled populations have difficulty choosing among health plans. Questions regarding how well the elderly population is equipped to choose a health plan in today's market, as well as in the future, when the market will have been fine-tuned, will prove to be important in determining accountability.
|
From page 45... ...
Furthermore, there is great potential for adverse risk selection. If health plans attract the healthier Medicare enrollees, the sicker, more costly population will remain in the traditional Medicare fee-for-service system.
|
From page 46... ...
STRUCTURING CHOICE: A LOOK AT MODEL PROGRAMS7 An assessment of the leading purchasers that currently offer their employees a choice of health plans shows that these organizations take a variety of approaches to how they structure choice for their workers and the processes that they put in place to facilitate choice. The thresholds of participation that they set for health plans also vary a great deal.
|
From page 47... ...
These organizations also differ greatly in the degree to which they negotiate price. However, evidence from a variety of these leading purchasers and purchasing alliances -- such as Xerox, Edison International, the Health Insurance Plan of California, the Connecticut Business and Industry Association, and the Cooperative for Health Insurance Purchasing in Denver, Colorado -- demonstrates that they all place importance on the practice of creating a level field on which individuals can compare health plans.
|
From page 48... ...
Instead, CalPERS set high standards, focused on providing information to consumers, and let the health plans in the market compete. The agency uses a number of proactive procedures and checks and balances to ensure accountability by: • requiring all health plans to be licensed to do business by the California Department of Corporations; • gathering data from the plans on cost, performance and service, as well as externally driven data; 8Material provided by Tom J
|
From page 49... ...
Evidence from Minnesota and Edison International on Structuring Choice for Retirees9 Evidence from Minnesota and Edison International demonstrates that factors other than comparability of health plan benefits must be considered when structuring choice for retirees. Experience in these areas indicates that any entity dealing with this population must be prepared to devote considerably more time and resources to providing this group with information.
|
From page 50... ...
They include the "young old," who are vibrant and healthy, and those who are in greater need of health care services, many of whom suffer from chronic diseases. Although the members of this population are diverse, in general they can be classified as "vulnerable" for a variety of reasons, including their greater need for health care services and the higher health care costs that they incur.11 The needs of the Medicare population are different from the needs of many of those already enrolled in managed care organizations.
|
From page 51... ...
Some researchers note that the use of managed care systems may be the best way to ensure coordinated care for this population. To date managed care organizations have had little experience providing services to the Medicare population or treating older and sicker patients: just 10 percent of Medicare beneficiaries are enrolled in managed care risk plans.
|
From page 52... ...
Some managed care plans offer additional services and benefits not covered by traditional Medicare such as respite care, home inspections, physical adaptations for the home, relationships with community-based social service programs, support programs for people who are newly widowed, and group clinics for people with chronic illnesses. Several studies have found that whereas overall satisfaction and outcomes for beneficiaries in fee-for-service plans and HMOs are similar, HMO enrollees appear to be relatively less satisfied with quality of care14 and physician-patient interactions and 12Point made by Peter D
|
From page 53... ...
Most of the studies assessing how Medicare enrollees have fared in managed care plans have involved staff and group model HMOs, which are different from the current and emerging independent practice associations, PPOs, and provider service networks. Several key studies have looked at a variety of HMOs, however (Miller and Luft, 1994; Brown et al., 1993b)
|
From page 54... ...
However, new problems may arise if the pressure to reduce overall Medicare program costs leads to rationing or significantly affects plan and provider behavior.16 Until there is more documented experience, the Medicare population needs to be assured that they can disenroll from a managed care plan if they are not satisfied. The freedom to disenroll is especially important for the members of this population since they are unfamiliar with managed care and do not have experience dealing with this system.
|
From page 55... ...
. According to a speaker at the symposium, health plans have strong incentives to educate new enrollees as much as possible.
|
From page 56... ...
Anyone interested in more information on managed care can also request a copy of the Medicare Handbook and another HCFA brochure entitled "Medicare Managed Care Plans," which discusses how managed care works, enrollment issues, how to select doctors and hospitals, the advantages and disadvantages of HMOs, and disenrollment and appeals procedures (Cronin, 1996)
|
From page 57... ...
This information and other indicators that consumers find useful in evaluating health plans would be just as helpful to them in evaluating physicians in the fee-for-service system.23 The Importance of Comparability Without a clear picture of how managed care works there is great potential for dissatisfaction with managed care.24 Managed care represents a new paradigm for doing business, and consumers need to be educated about the potential benefits of this new system. It has to be made clear that managed care should not be regarded as the current fee-for-service system but with a richer benefit package and the same freedoms.
|
From page 58... ...
The incentives for the physician under a fee-for-service system are different from those for the physician under an HMO, in which the goal of the HMO is to make certain not only that coordinated, appropriate care is given but also that costs are controlled.25 Information That Interests Medicare Enrollees: Specific Plan Information26 In general, Medicare beneficiaries are most interested in information about how their plan works, how much it will cost them, if their physician is in the plan, and what benefits are covered. As shown in Table 2-2, the types of information in which Medicare enrollees are interested range from information on quality, to service, to accessibility and choice.
|
From page 59... ...
"What Information Do Consumers Want and Need: What Do We Know About How They Judge Quality and Accountability." Paper prepared for the IOM study Choice and Managed Care: Assuring Public Accountability and Information for Informed Purchasing by and on Behalf of Medicare Beneficiaries.
|
From page 60... ...
Whether a Medicare beneficiary gives any credence to the information provided has a great deal to do with who is providing the information. The Medicare population is highly cynical about who provides them with information; they do not trust health plans, providers, or insurance companies.
|
From page 61... ...
If consumers do not understand some of the information provided, insurance counseling groups, such as the ones operated by United Seniors Health Cooperative, can help them understand and interpret it.29 Other areas of disclosure involve the performance of a health plan in terms of both quality and service. Although plans generally provide extensive information on covered benefits, costs, and required copayments, little information is available to con 28Comment by Lucy Johns.
|
From page 62... ...
At least six states have enacted legislation preventing health plans from utilizing "gag rules," or anticriticism provisions, which prevent a physician from disclosing financial incentives that may affect patient care. In addition, a bill has been introduced in Congress, H.R.
|
From page 63... ...
. In 31Unless otherwise noted, the material in this section is based on a presentation by Carol Cronin.
|
From page 64... ...
There needs to be a place where a Medicare beneficiary can go for unbiased, objective information, preferably where a beneficiary can talk to someone in person or via the telephone. Role for Information Facilitating Organizations Since Medicare beneficiaries expressed a preference for receiving unbiased information through sources other than the health plans themselves or even through employers or government, symposium participants indicated the usefulness of thirdparty organizations.
|
From page 65... ...
Nonprofit Counseling Organizations Other organizations, such as the United Seniors Health Cooperative, operate counseling programs to educate seniors about their health care options. The health insurance counseling program for United Seniors receives calls and letters from seniors all over the country.33 ENROLLEE SATISFACTION AND CONSUMER PROTECTIONS34 National surveys on consumer satisfaction in Medicare HMOs have been conducted, but the information they offer is limited, and there are concerns that they are not useful indicators of the quality of care that an HMO provides.
|
From page 66... ...
Enrollees in managed care plans have expressed a variety of concerns about obtaining access on the telephone, long waiting times for appointments, and physicians who do not spend enough time with patients and who do not appear to be sympathetic. Surveys of managed care plan enrollees indicate that dissatisfaction with plans often arises from a lack of understanding about how the plan operates or the services that it covers.
|
From page 67... ...
The project's goal is to develop appropriate consumer satisfaction instruments and then to make certain that the information collected is comparable across health plans. The project will consider what literacy level the information should be targeted to and the level of cognitive skills people need to process the comparative information.
|
From page 68... ...
Those more likely to disenroll also reported problems obtaining access to care. A 1989 study comparing Medicare HMO enrollees with enrollees in fee-for-service plans found that about 18 percent of the Medicare HMO enrollees disenrolled within a year and a half.
|
From page 69... ...
If standards are set too low or if oversight and enforcement actions are weak, abuses and scandals such as those in Florida with Medicare managed care could arise.38 Standardization may help consumers to make better choices in a complex and increasingly competitive health care market. As an example, the federal government overhauled the Medigap 37At the symposium, Shoshanna Sofaer referred to a study that she conducted in 1986, the Health Insurance Decision Project.
|
From page 70... ...
Since Medicare beneficiaries lack knowledge about Medicare and the choices available to them, it is important to safeguard Medicare beneficiaries against potential marketing abuses. Although Medigap insurance currently allows door-to-door marketing, symposium participants expressed concern that door-to-door marketing by Medicare managed care plans should not be allowed since the elderly, more than any other group, rely on personal, one-on-one interactions for most of their information.
|
From page 71... ...
Although HCFA may spend $10 million on consumer education and all of the states combined may spend the same amount, health plans devote far greater amounts to marketing activities. Grievance and Appeals Procedures The majority of appeals filed with HCFA by Medicare beneficiaries are over disputes over payment for services provided by nonplan providers and emergency care (Network Design Group, 1995)
|
From page 72... ...
In the past HCFA has made little effort to inform Medicare enrollees of their choices regarding health care providers, treatment options, or competing private health plans. There have been several exceptions, including the disclosure of nursing home inspections, public listing of highmortality hospitals, mailings containing preventive care information, and some use of centers of excellence arrangements.
|
From page 73... ...
Department of Defense and FEHBP, has joined a group of large employers through the Foundation for Accountability to develop performance measures that will assist purchasers and consumers in choosing health plans. Historically, HCFA has been successful at obtaining and analyzing volumes of data, but it has been less successful at 42Material presented by Kathleen M
|
From page 74... ...
For example, low-birthweight measurements on report cards can be affected by socioeconomics, education, and nutrition, not just the care that is received through a health plan. But in the absence of any other measurements, symposium participants agreed that HEDIS and the quality measurements offered by NCQA represent a promising start.
|
From page 75... ...
PROPOSED LEGISLATIVE CHANGES TO THE MEDICARE RISK PROGRAM: A "REPORT CARD" From the perspective of Medicare beneficiaries and with a focus on issues of accountability and informed purchasing, the committee asked David Kendall to reflect on the various themes and findings that had been highlighted during the symposium and how those related to the Medicare reform provisions introduced as part of the Balanced Budget Act of 1995 and the Clinton administration's proposal. How much of what had been said and suggested during the symposium was reflected in the various provisions?
|
From page 76... ...
This approach requires plans to comply with a hefty range of rules and regulations regarding access, provide adequate ser TABLE 2-3 Medicare Legislation Report Card: Medicare Reform Provisions of the Balanced Budget Act of 1995 (H.R.
|
From page 77... ...
Similarly, payments to plans are not based on competitive bidding or contracting, but continue to use government-set payments, based on modifications to the current AAPCC system and, in the case of the congressional legislation, based on further national per capita growth limits.46 With regard to purchasing style, both proposals support the FEHBP approach in which the federal government offers all plans that meet the conditions of participation and do not permit more selective and active purchasing based on performance, a strategy used by many employers to ensure accountability and value. Both proposals would generally let the market prevail in the range of plan choices to be offered to beneficiaries.
|
From page 78... ...
(New enrollees in managed care plans would have a 90-day grace period for disenrollment.) The Clinton administration's proposal would shift the responsibility for enrollment from the health plans to the Office of the Secretary of the U.S.
|
From page 79... ...
Second, the bill does not demand sufficient requirements for disclosure on how financial and coverage decisions are made by individual health plans. This issue has particular importance for beneficiaries, many of whom suffer from chronic conditions.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.