isfaction and mechanisms to address consumer complaints through appeals processes and government oversight. The paper is divided into five sections. The next outlines current research evidence on Medicare HMO enrollee satisfaction. The the appeals processes available to Medicare health plan enrollees unhappy with plan coverage, payment, access, and other performance issues are then outlined. Current roles and standards of the federal and state governments in regulating managed care are then described. Consumer protection policy issues that arise in a competitive Medicare market are identified and the paper concludes with recommendations for further research and analysis.

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). Working Americans enrolled in HMOs are about as satisfied with overall plan performance as people receiving care on a fee-for-service basis. Health plan enrollees, however, are more likely to rate highly their plan's premiums and cost sharing and are less likely than their indemnity plan counterparts to be happy with physician-patient interactions or general ''quality" (Miller and Luft, 1994). People suffering from poor health or chronic conditions enrolled in managed care plans are more likely than those enrolled in fee-for-service plans to report problems (The Robert Wood Johnson Foundation, 1995). Analysts also have found that although Medicaid managed care improves access to care by several measures, enrollees are somewhat less satisfied than those in fee-for-service care, particularly if they do not remain with their personal physicians (Freund et al., 1989; Hurley et al., 1991).

Despite Medicare enrollees' overall high degree of satisfaction with managed care plans, it is important to understand the sources of complaints of those who are dissatisfied. Disenrollment is costly for plans and beneficiaries. Plans do not want to waste resources enrolling people who will not remain in the



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