Improving the Medicare Market Adding Choice and Protections (1996) / Chapter Skim
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J Medicare Managed Care: Protecting Consumers and Enhancing Satisfaction
J Medicare Managed Care: Protecting Consumers and Enhancing Satisfaction
Pages 290-325
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From page 290... ...
Any significant change in Medicare requires attention to the effects on its beneficiaries who may be unfamiliar with different delivery systems. Consumer protection is particularly important in a movement to enroll Medicare beneficiaries into capitated managed care organizations because of capitation's incentives to underserve and the greater health care needs of the elderly.
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From page 291... ...
MEDICARE MANAGED CARE: SOURCES OF SATISFACTION AND DISSATISFACTION Like most Americans, the vast majority of Medicare beneficiaries enrolled in managed care plans respond positively to surveys of consumer satisfaction (Adler, 1995; Ferguson, 1995; Minnesota Health Data Institute, 1995; Rossiter et al., 1989; Ward, 1987)
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From page 292... ...
Second, even when defined by a series of specific survey questions, "satisfaction" is a subjective concept that measures the extent to which one's personal expectations are met. Furthermore, surveys may not include people most likely to use services, such as those with chronic or acute illnesses, who may experience greater problems with access or provider conduct than healthier enrollees.1 Yet if financial incentives to enroll in managed care 1Regardless of whether Medicare HMOs currently receive favorable or adverse selection, which remains unclear, people with chronic illnesses and disabilities who are likely to use medical care represent a small proportion of the
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From page 293... ...
Finally, current Medicare research has examined only HMOs, although HCFA is experimenting with other kinds of managed care organizations, which might raise different consumer protection issues. Medicare HMO Enrollee Surveys The first published study to compare Medicare enrollees in the "risk contract" (capitated HMO)
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From page 294... ...
Respondents with various specific medical conditions or fair and poor health reported similar rates of satisfaction. To identify sources of dissatisfaction among HMO enrollees who might be more likely to have complaints, a recent study compares Medicare health plan enrollees with those who had disenrolled (Office of Inspector General, 1995)
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From page 295... ...
Focus Group Studies The most recent research on Medicare health plan satisfaction comes from two organizations that held focus groups in several U.S. cities among current and former Medicare HMO enrollees as well as people who had never enrolled (Frederick/ Schneiders, Inc., 1995; Gibbs, 1995)
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From page 296... ...
(As noted above, Minnesota Medicare HMOs have received high satisfaction ratings.) This study is included because it represents the most detailed review of Medicare HMO consumer problems.
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From page 297... ...
In a few instances, they forged signatures or lied about the significance of a signature on an enrollment form. State programs assisting Medicare beneficiaries choose health plans, and consumer advocates report that such sales practices remain current problems.
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From page 298... ...
found less use of home health care and poorer outcomes in Medicare HMOs than in the fee-for-service system.
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From page 299... ...
. Summary of Evidence of Medicare HMO Enrollee Satisfaction and Dissatisfaction Research on what makes Medicare HMO enrollees happy enough to stay in their plans or unhappy enough to desire to leave them reveals the following: • Most people are satisfied with their managed care plans (Ferguson, 1995; Minnesota Health Data Institute, 1995; Rossiter et al., 1989)
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From page 300... ...
Most disabled Medicare HMO enrollees report that they want to leave the HMO but are unable to do so because of inability to afford needed care under the fee-for-service system (Office of Inspector General, 1995)
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From page 301... ...
Disputes over Medicare-Covered Services Enrollee complaints are processed through Medicare's traditional five-step dispute resolution process if they involve (1) an HMO's refusal to pay for emergency or urgently needed services, (2)
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From page 302... ...
The annual rate of reconsideration requests per 1,000 Medicare plan enrollees filed with NDG ranged widely across plans, from none to more than 19 (Network Design Group, 1995)
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From page 303... ...
A study of the Medicare HMO experience in California concluded that beneficiaries themselves, hospital social workers, and other providers were unaware of the statutory appeals system or the HMOs' internal grievance processes, even though HMO enrollment materials described these systems in accurate detail (Dallek et al., 1993)
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From page 304... ...
. MEDICARE HEALTH PLAN ACCOUNTABILITY: PUBLIC OVERSIGHT Federal Medicare HMO Contracting Standards The Medicare statute and regulations prescribe contract standards for risk-bearing plans: either federal HMO qualification or other similar federal standards (regarding solvency, minimum enrollment, and administrative capacity)
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From page 305... ...
The 1995 Budget Reconciliation Conference Bill would have permitted provider-sponsored organizations (PSOs) to accept risk contracts to enroll Medicare beneficiaries without meeting requirements of state HMO solvency standards if they meet standards developed by the Secretary of the U.S.
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From page 306... ...
NAIC is currently developing several other model managed care laws, for example, to expand the requirements for health plan quality improvement systems and to prescribe standards for health care provider contracting by plans with limited provider networks. A recent analysis of the HMO licensure statutes and regulations in all 50 states concluded that most states regulate marketing activities and require basic benefits, protections against insolvency, consumer grievance systems, quality assurance plans, and external quality audits (Dallek et al., 1995)
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From page 307... ...
and could serve as models to strengthen Medicare risk-contracting standards. Some involve enrollee information, which could be especially useful in view of the fact that as many as 25 percent of Medicare HMO enrollees do not seem to understand plan constraints and procedures.
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From page 308... ...
PPO Regulation Preferred provider organizations (PPOs) emerged in the 1980s as networks of providers serve enrollees of health plans or self-funded employers (Rolph et al., 1987)
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From page 309... ...
To encourage integrated health care delivery, Iowa also has enacted authority for risk-bearing "organized delivery systems" that meet standards less demanding than those in the HMO law. State Oversight of Medicaid Managed Care Plans Because about 5 million Medicare beneficiaries are also eligible for Medicaid, they are affected by state regulation of Medicaid managed care plans (Saucier, 1995)
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From page 310... ...
plans and provider credentialing and either conducted patient satisfaction surveys or required HMOs to do so; about half required HMOs to report patient care data, review enrollee complaints, review utilization, and review medical records. Few states, however, require HMOs to use clinical practice guidelines; monitor patient outcomes; control physician practice through selection, education, or payment; or report problems with physician performance.
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From page 311... ...
In a time of potentially rapid change in Medicare health plan enrollment, it is important to develop federal and state regulatory capacities to monitor plan performance. • Several states have enacted HMO laws designed to address some of the problems experienced by Medicare beneficiaries related to marketing, access, emergency care, and plan capacity.
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From page 312... ...
As the foundation for a functioning market, the government should, at least, set standards for information that health plans must make available to prospective and current enrollees. The complexity of comparing plans suggests that the government should go further to compile and distribute accurate and detailed, yet simple and useful information to Medicare beneficiaries4 and support counseling programs that assist beneficiaries in using such data.
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From page 313... ...
Health plans, like Medicare HMOs, that promise not only future payment but also a service delivery system must have both financial capacity and a system to meet enrollee needs for covered services. This additional responsibility justifies regulatory standards that include, beyond financial solvency, an adequate provider network, access assurances, quality standards, and expedited appeals processes.
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From page 314... ...
A multivariate analysis involving Medicare enrollees in one HMO found that reported understanding of coverage and procedures to obtain care was the greatest predictor of enrollee satisfaction (Ward, 1987)
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From page 315... ...
, although this information might be difficult to convey in a simple and comprehensible way. It is not entirely clear what kind of information Medicare beneficiaries want in order to choose among managed care plans and other options.
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From page 316... ...
Neither the ICA program evaluation nor the few assessments of earlier programs for providing health insurance information to Medicare beneficiaries has demonstrated a clear effect on knowledge, attitudes, or decision making (Davidson, 1988)
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From page 317... ...
They could draw upon state HMO licensure laws and regulations in defining more precisely the adequacy of provider networks, definitions of medical necessity and emergency care, standards for specialty referrals, and time or distance standards. Requiring verification of new enrollment and including cautions about whether physicians with HMO contracts are accepting new patients also could prevent or eliminate some sources of dissatisfaction.
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From page 318... ...
Because state HMO licensure is currently required for Medicare risk contracts, it forms a floor for solvency and other standards and provides jurisdiction for state managed care regulators to monitor compliance with consumer protection standards. As the number and types of Medicare riskbearing health plans increase, this relationship could be formalized so that states monitor compliance with federally established standards.
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From page 319... ...
At least in the short term, the latter standard may be too restrictive. About 40 percent of Medicare beneficiaries filing appeals disenroll within 2 years of the disputed services (U.S.
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From page 320... ...
Although that project does not include Medicare beneficiaries, the instruments could provide models that could be tested on them in order to develop model Medicare consumer satisfaction survey tools. These current research efforts may be able to shed light on an issue not addressed in the literature, the cost to administer consumer satisfaction surveys and to compile and distribute their results.
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From page 321... ...
Although competition creates incentives for plans to determine what makes enrollees happy or unhappy, information on the state of the art of Medicare HMO managed care could be useful to policy makers to set contract standards and promote innovation. It would be interesting to know, for example, whether more mature HMOs or those with more experience enrolling the elderly have more satisfied enrollees.
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From page 322... ...
CONCLUSION Policy makers need to understand the sources of satisfaction and dissatisfaction of Medicare health plan enrollees. Such information can be useful to help prospective enrollees understand plan features in order to enroll in plans most likely to meet realistic expectations, provide the basis for establishing Medicare contract standards, and monitor contract compliance.
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From page 323... ...
Some of the confusion, concern, and dissatisfaction about Medicare managed care may subside as working Americans currently familiar with managed care plans age into Medicare. However, especially during the transition to a system very different from that which most elderly people have previously experienced, public agencies have a responsibility to set and enforce standards to protect Medicare beneficiaries and to ensure expeditious disenrollment and expedited grievance mechanisms.
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From page 324... ...
1995. Consumer protections in state HMO laws.
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From page 325... ...
1989. Patient satisfaction among elderly enrollees and disenrollees in Medicare health maintenance organizations.
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