Improving the Medicare Market Adding Choice and Protections (1996) / Chapter Skim
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3 Findings and Reccomendations
3 Findings and Reccomendations
Pages 80-110
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From page 80... ...
Number and Type of Health Plans to Be Offered Findings Medicare beneficiaries are currently offered traditional Medicare, Medigap policies, and, in many areas of the country, a growing number of alternative health plans. New initiatives in Medicare and proposed reforms of the Medicare program would 1For the purpose of this chapter, the term Medicare choices is an umbrella term for traditional Medicare, Medigap insurance, and alternative health plans (including managed care)
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From page 81... ...
Unlike private employers, which have the power to limit the number and types of plans offered, current Medicare practice and proposed reforms would allow any plan that meets specified conditions of participation to sell coverage to Medicare beneficiaries. Although the committee was cautioned that a large number of choices may increase the confusion for Medicare beneficiaries, it may also increase the ability of Medicare beneficiaries to find a plan that they like, for example, a plan that includes their chosen doctor, that offers valued additional coverage, or that provides convenient access to services.
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From page 82... ...
The Traditional Medicare Program Findings Given how little is known about ensuring informed choice and holding health plans accountable for providing quality care to Medicare beneficiaries and given the consequent risks for the beneficiaries, the committee believes that traditional Medicare must remain an option and a safe harbor for beneficiaries.4 This option should be at least as good as the existing Medicare program in terms of benefits, beneficiary cost-sharing, choice of providers, geographic access, and other factors. The committee believes that maintaining traditional Medicare as a choice is critical for allowing large numbers and a wide range of plans to be offered to Medicare beneficiaries.
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From page 83... ...
As improved technology for measuring risk selection is developed, HCFA should study the traditional Medicare program's risk pool relative to those of other health plans and assess whether program funding fairly reflects Medicare's risk profile to enable it to offer a product of competitive value to beneficiaries. The federal government should also study and pilot test ways to pay health plans more fairly for chronically ill beneficiaries to encourage health plans to invest in and market to those beneficiaries.
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From page 84... ...
The number and range of health plan choices being proposed for Medicare beneficiaries and variations in benefits, premiums, and marketing are likely to greatly increase the potential for risk selection among those offering the various Medicare choices. Since risk selection can seriously undermine the viabilities of the traditional Medicare program and individual plans, it is important that this problem be addressed and controlled.
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From page 85... ...
• Managed care uses practice protocols and definitions of what constitutes medical necessity and appropriate care that vary from those used by the traditional Medicare program. These differences can result in various types and levels of service for specific illnesses and conditions.
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From page 86... ...
Beneficiaries should be allowed to return to their previous Medigap policy with no additional premium costs and with no restrictions placed on preexisting conditions if they disenroll from a health plan within 90 days and return to the traditional Medicare program. The committee would like to see the federal government encourage plans to offer adequate out-of-area coverage for their enrollees who reside out of the plan's service area for more than 3 months.
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From page 87... ...
Subrecommendations The committee recommends that the existing appeals process be strengthened, streamlined, and better publicized. Furthermore, the committee recommends that the federal government make available an expedited review and resolution process for Medicare choices (by an agency independent of the health plan and the traditional Medicare program)
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From page 88... ...
Many Medicare beneficiaries are particularly vulnerable in their need and desire for adequate health care coverage and have been found to have low levels of understanding of Medicare choices. All of these factors that make elderly beneficiaries especially susceptible to improper marketing practices are underscored by the fact that elderly people have a preference for and rely on one-to-one interactions as a way of learning about their health plan options.
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From page 89... ...
Information and customer service techniques and protocols developed in the private sector should be used to guide this effort, and the best technologies currently available or pro jected to be available in the near term should be used. Beneficiary Information Needs for Informed Choice Findings Many Medicare beneficiaries do not understand the Medicare choices.
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From page 90... ...
Subrecommendations In efforts to communicate the information in Box 3-1, "Medicare Choices: Information for Beneficiaries," to Medicare beneficiaries, a broad range of mass media and other forms of communication should be used. Emphasis should be placed on providing beneficiaries with easy telephone access to individuals who can guide them on the use of the materials providing comparisons of health plans and who can provide additional clarification and information on plans and providers.
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From page 91... ...
An example cited frequently at the symposium and in the commissioned papers is the notion of customer service centers that allow telephone access to representatives with on-line support. The central availability of the federal government's access to standard data from participating health plans, the traditional Medicare program, and Medigap insurance offers an opportunity to use this tech
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From page 92... ...
2. How traditional Medicare and Medigap insurance, in comparison with alternative health plans, pay and contract with providers, for exam ple, choice of providers and portability.
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From page 93... ...
6. A clear description of the details of each plan and the Medigap policy, including • in- and out-of-network access and costs; • how referrals are made (e.g., who makes the referral decisions and on what basis)
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From page 94... ...
The Center would strive to offer Medicare beneficiaries national and regional or local access to the types of services provided by the benefits departments of the nation's large employers, building on the regional-area work of organizations such as ICA programs. The Center will provide education, counseling, and legal assistance and will process complaints, grievances, and appeals from plan members through regional and local agents such as ICA programs.
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From page 95... ...
. Choice Facilitating Organizations Findings The committee finds that many independent private organizations that already exist or that might well develop can assist beneficiaries with making informed choices among the options available through the Medicare program.
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From page 96... ...
One committee member raised some additional concerns about these organizations which are outlined in Appendix A To help make the Choice Facilitating Organizations as useful to beneficiaries as possible, the federal government should require health plans and the traditional Medicare program to make available appropriate information to such organizations that have a legitimate interest in that information, such as the data behind quality or accreditation scores.
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From page 97... ...
RECOMMENDATION 4 The federal government should require all Medicare choices to be marketed during the same open season to promote comparability and to enable beneficiaries to adequately as sess and compare the benefits and prices of the various op tions. Coordination of Traditional Medicare, Medigap Insurance and Health Plans: Medicare Choices Findings Comparing the prices and benefits of the various Medicare choices is difficult at present because they are not marketed at the same time or under the same ground rules.
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From page 98... ...
.5 The federal government should work with state governments to coordinate the federal requirements surrounding Medicare choices with existing state regulations for Medigap insurance and private insurance.
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From page 99... ...
Health plans would be free to offer and price benefit packages other than these two that add to the basic benefit, but these other packages must be clearly identified as nonstandard, must offer substantial differences from the basic benefit package, and would not be included in the Medicare Customer Service and Enrollment Center's standard published comparisons. The federal government should commission the Medicare Customer Service and Enrollment Center to develop and use formats that allow beneficiaries to make easy and clear comparisons of benefits and other information on Medicare choices, drawing on the best practices used by employers and private and public organizations.
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From page 100... ...
Because of the inherently personal nature of the physician-patient relationship and its special importance to elderly patients, the committee is concerned about the increasing restrictions on physicians (and the potential conflict of interest of physicians) when they act in their professional role as advocates for their patients and carry out their contractual responsibilities and receive economic incentives as health plan providers.
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From page 101... ...
The committee recommends that the federal government require plans to disclose to plan enrollees how physicians get paid, whether they are rewarded for withholding referrals, and any other restrictions affecting how physicians can inform or treat plan enrollees. Similarly, educational materials should make clear the incentives in traditional Medicare and Medigap insurance to provide unnecessary care and the risks of these incentives.
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From page 102... ...
Thus, a beneficiary's choice of health plan can affect not only whether services are covered but also how they are provided. To further the responsiveness of plan management and providers to the special needs and demands of Medicare beneficiaries, the committee suggests that plans actively and meaningfully include beneficiaries in their governance and board activities and otherwise integrate the consumer voice into the plan's management and decision-making structure.
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From page 103... ...
To capitalize on this potential, the quality of service provided by health plans must be measurable and must be communicated to beneficiaries in a way that is relevant to them so that quality can be taken into account and so that a beneficiary can make an informed choice. Choice in health care, as in any environment, also introduces incentives to restrict the provision of or payment for services to remain competitive.
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From page 104... ...
104 IMPROVING THE MEDICARE MARKET BOX 3-2 Conditions of Participation The committee recommends that all Medicare choices meet the fol lowing minimum standards: • participate in the annual open season and sell policies to Medicare beneficiaries during that open season or on certain other occasions, such as when a beneficiary first becomes eligible; • offer open enrollment, guaranteed renewal, and no clauses pre cluding enrollment because of a preexisting condition for newly eligible beneficiaries and for beneficiaries changing plans; • offer Part A and B benefits (except for Medigap policies) and meet other Medicare benefits requirements; • provide information specified by the federal government to ensure informed choice by beneficiaries; • meet quality certification requirements comparable to those already in use and in development by recognized national private accrediting entities and require appropriate progress and improvement against such standards over time; • have resources, including appropriate mixes of specialists and re ferral resources, to provide benefits throughout service areas to a rea sonable degree defined by the federal government so as not to divide metropolitan areas or counties except when natural barriers or other con ditions divide service areas; • provide a user-friendly, well-communicated, and responsive ap peals and grievance process and allow retroactive disenrollment of ben eficiaries who are determined by a fair and appropriate process to have misunderstood the implications of their choice and who have suffered serious financial or other consequences; • meet fair marketing standards; • meet specified fiscal solvency and financial disclosure require ments, allow compliance audits of financial and quality assurance opera tions, agree to use federal government-promulgated terms for describing coverages, and agree to accept enrollees without prejudice in all circum stances and particularly when the beneficiary has been enrolled in a plan that has gone out of business or become insolvent within the prior 60 days; • not discourage providers from advising patients regarding their treatment options and plan coverages; • provide such data to the federal government as required for it to test the plan's performance and compliance; and • provide such information as it may require to the Medicare Custom er Service and Enrollment Center.
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From page 105... ...
The federal government might well foster competition and innovation among private credentialing agencies for different aspects of this function. Communication with beneficiaries about the quality of a health plan and traditional Medicare plans should be done by the Medicare Customer Service and Enrollment Center by using the latest information available from credentialing processes and the latest techniques for communicating plan performance.
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From page 106... ...
The committee lauds the efforts under way in HCFA, PPRC, a number of health foundations and other groups to track and address key issues that could arise in monitoring access to care under a restructured Medicare program. Subrecommendations Broad access for Medicare beneficiaries is key.
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From page 107... ...
For example: • The administration of the multiple choice program and the management of the traditional Medicare programs involve very different missions and orientations. • The two functions require different types of management, staff expertise, backgrounds, and knowledge.
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From page 108... ...
Subrecommendations The committee believes that these growing choice management functions would benefit from an organizational identity with the stature to facilitate recruitment of the needed leadership and staff and to build public trust. For that reason the committee recommends that serious consideration be given to establishing a new function along the lines of a Medicare Market Board, Commission, or Council that would include an advisory committee with key stakeholders (i.e., purchasers, providers, and consumers)
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From page 109... ...
• Health plan standards -- Consult experts and conduct research and demonstrations to refine the conditions of participation by health plans on an ongoing basis to reflect the service and quality that the government expects for Medicare beneficiaries, regardless of the plan that they choose. The conditions would be set on a national basis and would be measurable and subject to an annual evaluation of compliance.
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From page 110... ...
Congress on the extent to which beneficiaries are able to make informed choices, the extent to which government and beneficiaries are succeeding in holding plans accountable for ensuring quality of care and containing costs, and ways to improve the system's performance. -- Review traditional Medicare and health plan costs and performance to determine whether the amount and form of the federal government's contribution to costs (e.g., premium payment)
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