Improving the Medicare Market Adding Choice and Protections (1996) / Chapter Skim
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G Medicare Managed Care: Issues for Vulnerable Populations
G Medicare Managed Care: Issues for Vulnerable Populations
Pages 195-235
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Public Policy Institute, American Association of Retired Persons, Washington, D.C. 1A definitive conclusion on whether managed care generates true savings must rest on whether the rate of growth of health expenditures is reduced over time.
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(Health Care Financing Administration, Office of Managed Care Operations and Oversight Team, 1995b)
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Finally, the unique responsibility of public (versus private) purchasers to safeguard the interests of Medicare and Medicaid beneficiaries is identified and the protections that are needed by vulnerable populations enrolled in managed care plans are described.
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The racial compositions of those living in urban and rural areas were similar, with whites making up about 84 percent of the beneficiary population in urban areas and 87 percent in rural areas (Health Care Financing Administration, 1995)
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In 1994, among Medicare beneficiaries, 46 percent were between 65 and 74 years of age; as a percentage of total Medicare enrollees, the number of people in this age group has been steadily declining (Health Care Financing Administration, Bureau of Data Management and Strategy, 1995; Health Care Financing Administration, Office of Research and Demonstration, 1995)
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Health Status Data from the Medicare Current Beneficiary Survey indicate that when asked how each would rate his or her own health compared with the health of others the same age, almost 46 percent of aged Medicare beneficiaries rated their health as excellent or very good, a proportion that is considered "remarkably stable" across all age groups (Adler and Phil, 1995)
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Self-assessed health status also differs markedly by disability status and race. Only 17 percent of disabled beneficiaries and approximately 25 percent of African Americans reported their health as excellent or very good (Adler and Phil, 1995; Health Care Financing Adminstration, 1995)
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. The top 10 chronic conditions for people over 65 years of age in 1989 were arthritis, hypertension, hearing impairment, heart disease, cataracts, deformity or orthopedic impairment, chronic sinusitis, diabetes, visual impairment, and varicose veins (U.S.
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. Likewise, in 1992, those over age 65 averaged 2,711 hospital days per 1,000 persons compared with about 456 days per 1,000, for persons 0 to 64 years of age (Gabel et al., 1994; Health Care Financing Administration, Bureau of Data Management and Strategy, 1995)
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In 1993, 30 percent of all Medicare beneficiaries had annual incomes under $20,000; more than 20 percent had annual incomes under $10,000 (The Public Policy Institute/American Association of Retired Persons, 1995, using Current Population Survey data) (Table G-2)
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In 1995, nearly 5 million Medicare beneficiaries received some assistance from Medicaid (Health Care Financing Administration, 1995)
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129) note that "because norms of appropriate treatment are ill-defined for many chronic conditions, it is difficult to determine if reduced spending or shifts in the nature of service have led to poorer outcomes." Most managed care plans have had little experience treating older, sicker, or disabled patients (Armstead et al., 1995; Tanenbaum and Hurley, 1995)
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In focus groups conducted in 1995, the greatest concerns expressed by seniors who were not enrollees in managed care plans were the restrictions on physician choice and the perceived lower quality of care in HMOs (Frederick/Schneiders, Inc., 1995)
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(3) Despite these differences, outcomes were similar for HMO and fee-for 2Nevertheless, the Mathematica study also reported that Medicare risk HMOs have increased estimated costs to HCFA by 5.7 percent more than it would have spent had the HMO enrollees remained in the traditional Medicare program (Brown et al., 1993)
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. The fact that HMO enrollees experienced less relief from joint pain is a concern, because arthritis is a chronic condition commonly found among elderly persons and, in the view of Clement et al., "should have been better ameliorated." Clement has suggested that failure of HMO patients to have experienced improvement similar to those in fee-for-service plans could reflect an overall lack of knowledge about the management of chronic illnesses in the elderly (Winslow, 1994)
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. Although the studies noted above are examples of evidence that HMOs have satisfactorily treated older or chronically ill patients, there is also evidence in the research literature that finds this model wanting with respect to vulnerable populations.
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Shaughnessy and colleagues noted that the findings were most pronounced among HMO patients whose care was contracted out to home health agencies. Thus, the ways in which managed care plans organize the provi 4"Comprehensiveness" measured the total number of health care visits and the number of visits during the preceding 6 months.
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. Outcome studies of HMO patients with serious mental illness show conflicting findings (Christianson and Osher, 1994)
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. A recent survey of enrollees in managed care plans found that nonelderly sick enrollees reported more problems getting the health services that they or their providers believed that they needed and more difficulty getting to see specialists than those in fee-for-service plans (The Robert Wood Johnson Foundation, 1995)
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However, an earlier look at disenrollment in the Medicare Competition Demonstrations found that, "among the variables that indicate an association between health status and disenrollment, only the amount of Part B Medicare expenditures prior to joining the HMO ap
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The term "best practices" should be reserved for those that have been tested and evaluated on the basis of the quality and cost-effectiveness of the care provided. Nevertheless, many managed care plans are actively involved in demonstrating different approaches to the provision of care of their vulnerable populations (see, e.g., Group Health Association of America, 1995a; Health Care Financing Administration, Division of Policy and Evaluation, Office of Managed Care, 1994)
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have been addressed. It would seem that managed care plans are logical settings for the implementation of "population-based medicine," "a strategy for designing and implementing an organized approach to providing for the care of clinical problems, particularly chronic problems, through the application of epidemiologic principles and data" (Voelker, 1994; Wagner et al., 1995a, p.
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Practices of Some Medicare Managed Risk Program HMOs Kramer and associates (1992) have described the geriatric care provided by group/staff model Medicare HMOs.
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Primary Care Model for Chronic Care Illness In considering a basic care model for chronically ill patients, Wagner and colleagues (1995b) have identified current deficiencies in the care of chronic illness: irregular or incomplete assessments, inadequate or inconsistent patient education, unintended deviations from accepted guidelines, and patient dissatisfaction
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At each miniclinic session: "planned assessments, visits, and a group meeting; standardized assessment of clinical and health status; development and execution of care plans constructed mutually with patients incorporating practice guidelines and reminders; continuous individual patient education; opportunities for group support; and systematic follow-up" are envisioned (Wagner et al., 1995a, p.
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There have been several demonstrations to integrate acute and long-term-care services, most notably the Program of All-Inclusive Care for the Elderly (PACE) /On Lok projects and the Social Health Maintenance Organizations.
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Operating under the flexible benefits option of HCFA's Medicare Managed Risk Program, SeniorCare Options is a Medicare risk plan that offers Medicare beneficiaries "open access" to approximately 6,500 providers, including primary care and specialists. For a slightly higher premium, enrollees may self-refer directly to specialists.
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. Case Management The Chronic Care Initiatives in HMOs studied the use of case management in 18 HMO Medicare risk contractors having more than 20,000 members and five other plans that did not meet this enrollment criterion.
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They found that the programs fell along a continuum based on the intensity of contact with the patient. At the highest levels of intensity, case management resembled the activity in social health maintenance organizations, whereas at the lowest intensity, it resembled "an elaborate utilization review model" (Pacala, undated, p.
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Managed care plans must demonstrate and document the ongoing effectiveness of their internal quality review processes through performance measurements and external reviews. New performance measurement systems should include measures of access to and timeliness of care, the appropriateness of the setting and treatment, and premature hospital discharges.
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. Indeed, many private purchasers rely solely on accreditation as a means of distinguishing among managed care plans.
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However, in the Medicare program, 90 percent of beneficiaries still receive their care through traditional fee-for-service arrangements. Although this may change over time, it is not yet certain whether enrollment in managed care plans among older Americans will reach the same level as that among individuals in the private sector.
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Medicare beneficiaries are substantially different from those who have typically enrolled in managed care organizations. Several of the researchers whose works were cited in this paper observed indications that the plans studied lacked experience dealing with particular types of chronically ill patients or did not understand the importance of certain treatment modalities that are of importance to those with chronic care needs (e.g., Clement et al., 1994; Shaughnessy at al., 1994)
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It is disturbing that these practices are still commonly found in physician incentive programs of managed care plans. Many are advocating for the disclosure of the financial incentives used by managed care plans.
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Health Care Financing Rev.
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Chronic Care Initiatives in HMOs. (undated)
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Washington, D.C.: Government Printing Office. Health Care Financing Administration, Office of Managed Care (Operations & Oversight Team)
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managed care risk plans. Health Care Financing Administration, Baltimore, Md.
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Final Report. Washington, D.C.: Chronic Care Initiatives in HMOs.
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Project summary presented at the Robert Wood Johnson Invitational Conference on Chronic Care Initiatives in HMOs, Washington, D.C., April 27-28, 1995. Shaughnessy, P
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C (Administrator, Health Care Financing Administration, U.S.
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