Index

A

Access to care

financial barriers, 210-211

information needs, 277

organizational barriers, 211

physicians, 343-344

rehabilitative services, 71

satisfaction with, 65, 67, 300

underserved populations, 105-107

verification of, 49

Accreditation and accrediting organizations, 41 n.2, 105, 106, 156, 167, 169, 225, 318-319

Acute-care, integration with long-term care, 220-221

Acute disease paradigm, 215-216

Adjusted average per capita cost (AAPCC), 14-15, 16, 77, 84, 152, 170, 227

Advocacy/advocates, 42-43, 61, 154, 207, 315-316

Aetna, 176

Agency for Health Care Policy and Research, 5, 34, 67, 156, 245, 275-276, 285, 320

Alabama, 261

Alaska, 262

Allina Health Plans Group, 32, 221

Ambulatory care, 58, 273-274

American Association of Health Plans.

See Group Health Association of America

American Association of Retired Persons, 60, 63, 155, 249, 260

American College of Physicians, 271

American Heart Association, 259

Anticriticism clauses, 10, 62, 100

Appeals procedures, 62, 71-72, 84, 86-87, 225-226, 299, 301, 316, 318, 332, 350

Appropriateness of care, 101, 103

Area Agency on Aging, 261

Arizona, 52, 196, 252-253, 307

Arizona Senior World, 252

Arthritis, 53

B

Baby boom generation, 1

Balanced Budget Act of 1995, 5, 33.

See also Omnibus Budget Reconciliation Act of 1995

Beneficiaries, Medicare.

See also Communication with



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--> Index A Access to care financial barriers, 210-211 information needs, 277 organizational barriers, 211 physicians, 343-344 rehabilitative services, 71 satisfaction with, 65, 67, 300 underserved populations, 105-107 verification of, 49 Accreditation and accrediting organizations, 41 n.2, 105, 106, 156, 167, 169, 225, 318-319 Acute-care, integration with long-term care, 220-221 Acute disease paradigm, 215-216 Adjusted average per capita cost (AAPCC), 14-15, 16, 77, 84, 152, 170, 227 Advocacy/advocates, 42-43, 61, 154, 207, 315-316 Aetna, 176 Agency for Health Care Policy and Research, 5, 34, 67, 156, 245, 275-276, 285, 320 Alabama, 261 Alaska, 262 Allina Health Plans Group, 32, 221 Ambulatory care, 58, 273-274 American Association of Health Plans. See Group Health Association of America American Association of Retired Persons, 60, 63, 155, 249, 260 American College of Physicians, 271 American Heart Association, 259 Anticriticism clauses, 10, 62, 100 Appeals procedures, 62, 71-72, 84, 86-87, 225-226, 299, 301, 316, 318, 332, 350 Appropriateness of care, 101, 103 Area Agency on Aging, 261 Arizona, 52, 196, 252-253, 307 Arizona Senior World, 252 Arthritis, 53 B Baby boom generation, 1 Balanced Budget Act of 1995, 5, 33. See also Omnibus Budget Reconciliation Act of 1995 Beneficiaries, Medicare. See also Communication with

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-->   beneficiaries; Information needs of beneficiaries age, 198-200 with chronic health problems, 202-203 committee focus, 7 demographics, 23-25, 196 disabled, 196, 198, 202-203 disenrollment, 54-5 diversity, 37, 50-51 dually eligible, 7, 37 elderly, 11 end-stage renal disease, 11 experiences in managed care, 2, 206-215 health outcomes, 208-213 health status, 25-27, 50, 200-202 in HMOs, 4, 51-54, 196, 290 income and poverty status, 203-205 information of interest to, 271, 275-282 knowledge about benefits/Medicare, 27-28, 56, 241-242 minorities, 198 number, by state, 18-19 out-of-pocket expenditures, 206 patient satisfaction, 213-214 qualified, 13, 205 range of options, 80-82, 191 rights, 332 role and responsibility, 33 severely disabled, 7, 11, 37 utilization of services, 203 vulnerable population, 50, 197-198 Benefit plans comparison charts, 57-58, 73, 78, 89, 97-99, 161, 224, 247-248 design, 161-162, 164-166, 173, 176-177, 192 information wanted by consumers, 58, 59 number and type offered, 161-162, 192 standardization, 47, 49, 69-70, 73, 98, 99, 161, 184, 186, 192, 344 -345 Benova, 255, 256, 260 Best practices. See also individual case studies benchmarks, 143, 151, 156-157 concept, 34 HMO, 320-321 in purchasing plans, 151-152 Bethlehem Steel, 250 Blue Cross and Blue Shield, 164, 294 Brook, Robert, 155 C California counseling programs, 316 Department of Corporations, 296, 342 disenrollment data, 249 dispute resolution process, 303 emergency care, 308 HMO enrollees, 16, 18, 152, 196 information on benefits, 61, 262 Knox-Keene Health Care Service Plan Act of 1975, 342 marketing abuses, 297 plan purchasing strategies, 152 reform legislation, 171 risk adjustment, 161 n.1 risk-based HMOs, 52 satisfaction with care, 147, 296-298 state oversight of HMOs, 171, 296, 307, 308 California Public Employees' Retirement System (CalPERS), 48-49 accountability measures, 48-49 background, 35-36, 340-342 benefit design, 344-345 cost and performance data, 346-348 customer service, 348-351 number of plans, 48, 150 purchasing role, 153 provider access, 343-344 requirements for participation, 342-348 statutory and regulatory compliance, 342 Capitation payments, 14-15, 21, 45 Cardinal Health, 259 Case management, 52, 221, 222-223 Center for Health Care Rights, 249, 296 Centers for Disease Control and Prevention, 259 Centers of excellence, 156-157 Choice of health plan options. See also Informed purchasing benefit plan designs and, 192

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-->   committee focus, 7 comparative information, 57-58, 73, 78, 89, 97-99, 161, 165, 170, 189-190, 194, 224, 334, 335 facilitating organizations, 95-96, 123-124, 187-193 model programs, 46-50 number of plans offered and, 48, 80-82, 148, 150, 161-162, 172-173, 175, 191, 192 objectives, 159-160 personal implications, 286 policy issues, 160-163, 193-194, 286 selection criteria, 160-161, 169 structuring, 46-50, 163 types of plans, 40 Chronic Care Initiatives in HMOs, 219, 222 Chronic illness conditions prevalent in elderly people, 50, 202-203 fair payment of providers, 83 group clinics for, 52 and information needs, 90, 277-278 model, 216 population-based approach, 53, 216 primary care model, 218-219 and provider financial incentives, 78, 79 and satisfaction with care, 66, 291 treatment demonstrations, 220-221 CIGNA, 176, 177 Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), 150 Clinton Administration reforms, 5, 33, 40, 76, 77-78 Committee case studies, 35-36 commissioned papers, 34-35 composition, 8, 38 focus, 6-8, 33-34, 36-38 study approach, 33-38 tasks, 4-5, 28-29 Commonwealth Fund, 25 Commonwealth Program for Patient-Centered Care, 271, 275-276, 283 Communication with beneficiaries. See also Consumer education; Consumer information; Information needs of beneficiaries community meetings, 244, 260-261 computer/electronic media, 63, 73, 90, 191, 239-240, 248, 256-258, 259, 281 direct mail, 242, 243 focus group research on, 243-245 friends/relatives/word-of-mouth, 242, 243, 244, 277 health fairs, 185 by health professionals, 243 importance, 271 information kiosks, 258-259, 281-282 literature review, 241-243 media approaches, 90, 237-241 newspapers and magazines, 251-253 one-on-one counseling, 49, 90, 94, 261-263, 265-266, 281, 282, 316 open enrollment sessions, 49, 242 overview, 63-64 pamphlets, reports, and guides, 56, 173-174, 177-178, 182, 185-186, 245-251, 263, 281, 282, 316, 334 preferred sources, 242-245 reading level, 55 recommendations, 90 segmentation of messages, 63 seminars, 244, 261, 316 by telephone, 49, 56, 64, 90, 91, 170, 182, 240, 243, 244, 250, 253 -254, 281, 282 television and radio, 238-239, 255, 263 videos, 49, 255-256 Community-based social service programs, 52 CompuServe, 258 Conditions of participation. See also Enrollment employer health plans, 175 Medicare managed care providers, 76-77 recommendations, 81-82, 101, 102-103, 104 Connecticut Business and Industry Association assessment of program, 178-179 benefits structure, 176-177, 192 enrollee information, 177-178, 189

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--> enrollment process, 178 participation rules, 177 plans offered, 149, 176 purchasing role, 175 Consolidated Omnibus Budget Reconciliation Act of 1986, 326 Consumer Assessments of Health Plans Study, 67, 245, 285 Consumer complaints, study of, 296-299 Consumer education, 190-191. See also Communication with beneficiaries and accountability, 153-155 and disenrollment, 54-55 by employers, 95, 169-170, 173-174, 249-250, 256 funding for, 64, 65, 71, 95, 96-97, 184-185 by health plans, 78, 79, 153-154, 167-168, 250-251, 253, 254, 255, 261 by insurance counseling programs, 64-65, 254 in libraries, 244, 248, 257 literacy considerations, 67 marketing conflicts of interest, 64, 70, 95 by nonprofit organizations, 65, 177-178, 249, 251-252, 257-258, 260-261 by private sector, 252-253, 259, 262 by public agencies, 72-74, 184-185, 244, 245-248, 253-254, 255-257, 258-259, 261-262, 334 research recommendations, 321-322 retirees, 49-50 and satisfaction with care, 57-58, 66-67, 85, 314-315 stages, 190 strategies, 153-155 Consumer information. See also Information needs of beneficiaries amount and types, 60-61, 67, 162-163, 173-174, 177-178, 188, 190-191, 225, 315 misleading, 62 objective sources of, 48, 56-57, 60, 63-64, 68-69, 71, 190-191, 278, 334 operational considerations, 187-190 patient-reported, 225 performance report cards, 49, 144, 145, 151, 167-168, 186 performance standards, 182 prototype materials, 278 responsibility for providing, 22, 78, 162-16 Consumer Information Center (Pueblo, Colorado), 245, 247 Consumer Information Project, 277 Consumer protection. See also Standards and standards setting accountability distinguished from, 30 counseling and advocacy services, 315-316 government role, 312-313 information safeguards, 68-69 policy issues, 312-313 standards, 316-317, 322 Consumer Reports, 245 Consumers definition of high-quality care, 271-274 patients as, 44 public accountability role, 42-43 Cooperative for Health Insurance Purchasing (Colorado) blending multiple market segments, 181-182 marketing, 180 number of plans offered, 148 performance standards and measurement tools, 182 structure, 180, 192 Cooperative Health Care Clinic, 219-221 Cost containment issues, 10, 58, 61, 68, 84, 100, 101 Cost data, 49, 346-347 Cost sharing. See Premiums and cost sharing strategies Counseling. See Insurance counseling groups Customer service, 49, 91, 94-95, 96, 97, 99, 316 D Deductibles and copayments, 13, 20, 47, 165, 167, 169, 344, 345

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--> Deficit reduction, 1, 6, 36 Delaware, 307 Delivery of health care services. See Service delivery Demographics Medicare managed care enrollees, 16-21 Medicare market, 23-25 Dental care, 19 Department of Veterans Affairs, 274 Diabetes, 331-332 Directories of physicians and benefit options, 49, 189 Disabled people/disability age, 200 capabilities for informed decision-making, 44 costs of care, 203 evaluation of impairment, 202-203 Medicare enrollees, 196 problems of, 202-203 satisfaction with care, 66, 295, 300 types of impairments, 202-203 Discrimination against high-risk patients, 26. See also Risk selection Disenrollment. See also Satisfaction with managed care consumer education and, 54-55, 297 costs, 286, 291-292 health status and, 214-215 information on, 61, 62, 249 on-line HCFA computer service, 55 prevention, 78 rates, 55, 61, 66 n.35, 67-68, 214-215, 299 reasons for, 67-68, 214-215, 280, 290, 294-295, 297, 304, 319 reenrollment, 14 retroactive, 55, 88, 297-298 rights of beneficiaries, 54-55, 86, 319, 330 Dispute resolution beneficiary understanding of, 303-304 HMO grievance process, 302-303 Medicare-covered services, 301-302 Medicare HMO process, 303-304 Dissemination of information. See Communication with beneficiaries; Consumer education; Consumer information Downs, Hugh, 255-256 E Ear examinations, 16, 20 Elder Service Plan, 220-221 Elderly people ability to make informed choices, 7, 24-25, 27, 28, 32-33, 37, 44 attitudes about managed care, 276 communication preferences and approaches, 237-241, 263-264 concerns of, 6, 7, 27, 36, 50 enrolled in Medicare, 11 expenditures for, 26, 199-200 health literacy, 4, 25, 27-28 income, 24, 25 market segments, 240-241 oldest old, 23, 197 own physician vs. HMO, 20-21, 27, 65 presentation of information to, 28 volume of services used, 2 Emergency care, 61, 71, 298, 300, 302, 308, 310 Employers (private sector) education of employees/retirees, 95, 169-170, 173-174, 249-250, 256 expenditures, 2 nonfederal public, 149-150 premium structure, 162 small, 171-177 Employers Health Purchasing Cooperative, 149 End-stage renal disease, 11, 14 n.1, 23, 66, 197, 198, 295, 330 Enrollment. See also Disenrollment consumer education during, 49, 347-348 customer service center, 91, 94-95, 96, 97 guidelines, 9, 86-87 incentives, 16, 20, 21

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--> lock-in provisions, 85, 86, 89, 297-298, 332 Medicare managed care, 14, 22, 27, 78, 330 minimums for participation, 151 open, 169, 173, 177, 192-193, 330 period, 192-193 recommendations, 84, 86 reenrollment, 14, 178, 192-193 strategies/processes, 14, 22, 27, 78, 169, 173, 177, 178, 192-193, 330 statistics, 18-19 traditional Medicare, 11-12, 18-19 Eye examinations, 16, 20 F Fallon Healthcare System, 220-221 Family HealthCare Services, 221 Federal Employees Health Benefits Plan, 41, 138, 146-148, 155, 157 Federal Trade Commission, 254 Fee-for-service plans and accountability, 142-143 grievances and appeal procedures, 72 home health care in, 211-212 information needs, 57, 277 Medicare, 39, 82-83 premiums, 166-167 private, 40, 78 quality of care, 210 satisfaction with, 290, 293-295 self-insured, 164 and utilization, 26 viability of, 82-83 FHP, Inc., 164, 180 Financial Accounting Standards Board, 156 Firman, James, 155 Florida HMO enrollees, 16, 18, 152, 196 plan marketing requirements, 307 plan purchasing strategies, 149, 152 quality of care, 69 risk-based HMOs, 52 satisfaction with care, 147 Florida Community Health Purchasing Alliances, 149 Focus group studies communication with older adults, 243-245 consumer education, 60, 63, 335 satisfaction with care, 66-67, 272, 273, 274, 284, 295-296 Foot care, 20, 60 Foundation for Accountability, 5, 34, 73, 103, 144, 156 Frederick/Schneiders, Inc., 276 Frontier Community Health Plans, 180 G Gag rules, 10, 62, 100 Georgia, 259 Geriatricians and geriatric assessment, 52, 217-218 Golf Digest, 239 Grievances and complaints communication of information on, 225-226, 316 HMOs, 302-303 Medicare-covered services, 301-302 Medicare HMOs, 303-304 monitoring and tracking, 49, 292 processes, 71-72, 84, 302-303 recommendations, 84, 87 reporting of, 154 review and resolution process, 87, 303-304 satisfaction with responses to, 61 Group Health Association of America (GHAA), 186, 243, 256 Group Health Cooperative of Puget Sound, 53, 154, 219 H Hawaii, 262 Health Care Financing Administration beneficiary/customer communications, 35, 333-335 educational materials, 56, 245-247, 253 educational role, 5, 72-74 financial review, 331

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-->   HMO monitoring processes, 35, 332-333 hotline, 244, 247, 253-254 marketing policy manual, 238 Medicare restructuring activities, 22-23, 34 Office of Managed Care, 73, 247, 255-256, 328 Office of Research and Demonstrations, 255, 335-336 ONLINE computer service, 336 oversight of managed care, 73, 305, 327, 328-333 patient satisfaction surveys, 320 quality assurance role, 73, 292, 310-311 recommended role, 83-84, 107-110 Small Business Innovation Research, 262 Health care market, structural change, 39-40 Health care professionals. See also Physicians public accountability role, 43, 155-157 Health care resources, geographic distribution, 44 n.4 Health Insurance Decision Project, 69 n.37 Health Insurance Plan of California (HIPC) assessment of program, 174 benefits, 173, 192 enrollee information, 173-174 plans offered, 149, 172-173 participation rules, 173 provider directory, 189 purchasing role, 153, 172 structure, 171-172 Health maintenance organizations (HMOs). See also Risk contract HMOs; Social HMOs accreditation requirements, 41 ''best practices" research, 320-321 cost containment, 58, 166 n.2 disclosures to enrollees, 153-154 gatekeeper functions, 300 HealthLink managers, 164 primary care, 210 reporting standards, 144 staff/group model, 210 state regulation, 305-308 Health Pages, 170, 252 Health Plan Employer Data and Information Set (HEDIS), 49, 73, 74, 90, 103, 144, 153, 167, 182, 189, 278, 336, 347 Health plans. See also Choice of health plan options consumer education by, 78, 79, 167-168, 250-251, 253, 254, 255, 261 high deductible, 40 number and type offered, 80-82, 148, 172-173, 175, 191 portability, 60, 61, 85 Health Professional Shortage Areas, 105 Health status and disenrollment, 214-215 of Medicare HMO enrollees, 201 retiree concerns, 50 and risk selection, 25-27 and satisfaction with care, 66, 291 self-assessed, 200-201 of vulnerable populations, 200-201 HealthChoice, Inc. (HCI), 260 HealthLink, 164, 167 HealthPartners, 282 Healthtouch, 259 HMO Colorado, 180 Home health services, 12, 53, 60, 211-212, 298 n.3 Home inspections, 52 Hospice services, 12, 330 Hospital Insurance Trust Fund, 12 Hospital services, inpatient, 12, 58, 273 House Committee on Ways and Means, 21 Humana (Florida), 154 I Idaho, 262 Ignagni, Karen, 256 Illinois Employer Benefits Alliance, 149 Immunizations, 16, 20 Indemnity plans, 161

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--> Individual practice associations, 168, 210, 280 Information, counseling, and assistance (ICA) programs, 43, 94, 248, 254, 255, 261-262, 315-316, 321, 334-335 Information needs of beneficiaries. See also Communication with beneficiaries; Consumer education; Consumer information appeal and grievance options, 72 benefit packages, 58, 59, 284-285 comparability of plans, 57-58, 73, 78, 89, 97-99, 161, 188, 224 coverage limits, 61, 79, 153 credentialing standards, 106 disenrollment rates, 51 financial, 61, 79, 96 focus group research, 243-245, 276-279 interviews with decision makers, 280-282 managed care system, 56 marketing-related, 88-89 Medicare program, 56 performance, 61-62 physician incentives and restrictions, 61, 62, 153, 154, 228 provider lists, 62 quality of care, 59-62, 103, 105, 224, 274-275, 283, 285 recommendations, 89-91, 92-93, 282-286 research on, 315 specific plans, 58-59 structural, 59, 61 terminology considerations, 99, 189 topology of, 284-285 Informed Choice Fund, 87, 95, 96-97 Informed purchasing. See also Consumer education; Consumer information assisted, 32 committee focus, 6-7, 8, 37 comparability charts and, 57-58, 73 consumer education and, 190-191 consumer information and, 162-163, 187-190 defined, 32-33 elderly's concerns, 7 facilitating organizations, 95-96 federal oversight (directed), 32 full disclosure and, 60-62, 101, 153-154 health literacy and, 4 illness-episode approach, 283 literature on, 34, 279-280 market competition and, 32 policy issues, 193-194 responsibility for, 32-33 and satisfaction with care, 85 selection approach, 160-161 Institute for Health Policy Solutions, 149 Insurance counseling groups, 61, 315-316, 334-335 Integrated provider networks, 308-309 Internet, 73, 90, 256, 257 Interplan reciprocity, 86 J Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), 90, 103, 156 Joint pain, 53 K Kaiser Family Foundation, 25-26, 63-64, 243 Kaiser Foundation Health Plan of Colorado, 219-220 Kaiser Permanente, 164, 168, 176, 180, 189, 216 Kendall, David, 75-76, 154-155 Kentucky, 149 L Lears, 239 Legislation. See also specific legislation Medicare Risk Program, 75-79 potential impact of, 336-337 proposed statutory changes, 318-319 reconciliation, 336-337

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--> Lewin-VHI, 149-150 LIA Health Alliance, 149 Libraries, information distribution through, 248, 257 Licensure, 69, 307, 311 Life expectancy, 199, 200 Long, Steve, 148 Long-term care, 52, 60, 220-221 LTV, 250 M Managed care organizations. See also Medicare managed care accountability for, 31 defined, 30 enrollment, 2 experience with vulnerable populations, 206-207, 227 financial information, 61, 78 marketing costs, 55 state regulation, 305-311 target membership, 50 types of providers, 2-3 types regulated, 313 Managed Risk Medical Insurance Board, 171, 172, 173 Marketing of Medicare choices abuses, 70, 87-88, 95, 145, 296-297, 314-315, 318, 349 administration, 10 blending market segments, 181-182 for comparability, 10, 97-98, 182 commissions/compensation arrangements, 88, 174, 178-179, 180 defined, 238 distinguished from education, 64, 70, 95 door-to-door, 70, 88, 318 information materials, 88, 179, 182, 250-251, 299 policy issues, 194 prohibited practices, 330 public oversight, 264-265, 330 by purchasing cooperatives, 71 recommendations, 10, 84, 87-89, 97-98, 99 rules of conduct, 88, 99, 330-331, 349 social marketing, 265 state oversight of, 307 telephone, 88, 254 Massachusetts, 262 Mathematica Policy Research, Inc., 67, 208, 298 n.3 McCarran-Ferguson Act, 317 Media, focus on discord and contention, 36 Medicaid, 13, 205, 309-311 Medical necessity, 101 Medical Savings Accounts, 21, 40, 77-78 Medicare Advocacy Project, 296 Medicare Beneficiaries Defense Fund, 249 Medicare choices administration of, 107-110, 141-142 context for government involvement, 139-141 demonstration project, 15-16, 22, 335-336 "Medicare choices," use of term by IOM committee defined, 9 n.3, 29-30; See also Choice of health plan options; Informed purchasing; Marketing of Medicare choices Medicare Competitions Demonstrations, 208, 214-215 Medicare Current Beneficiary Survey, 25, 67, 200 Medicare Customer Service and Enrollment Center, 91, 94-95, 96, 97, 99, 105, 109 Medicare Handbook,56, 73, 246, 247, 334 Medicare managed care appeals procedures, 62, 71-72, 86, 225-226 benefits, 21 comparability charts, 334 conditions of participation, 76-77, 81-82 cost sharing, 22 delivery of services, 215-223, 329-330 disenrollment, 54, 78, 214-215 enrollees, 2, 18-19, 54, 327-328 enrollment process, 14, 22, 27, 78, 330

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-->   experiences of vulnerable individuals in, 51-54, 206-215 50-50 rule, 41, 51-52, 151 financial and administrative requirements, 331 HCFA organization and approach, 328-333 health outcomes, 208-213 incentives for enrollment in, 21 information sources, 56, 333-335 marketing specifications, 330 membership requirements for providers, 329 monitoring by HCFA, 352-353 overview of requirements, 13-16, 326-336 patient satisfaction, 213-214 payments to plans, 14-15, 21, 77 population characteristics, 16-21 profit potentials, 146 purchasing style, 77 quality assurance, 331-332 research and demonstrations, 335-336 rights of beneficiaries, 332 savings, 195 n.1 standards for providers, 21, 150-151 statutory basis, 327 Medicare Managed Risk Program, 208, 221 Medicare market. See also Marketing of Medicare choices demographics, 23-25 federal role in, 312-313 health status, 25-27 information dissemination, 27-28 risk selection, 25-27 structural change, 39-40 Medicare Market Board, 107-110 Medicare Plus, 21 Medicare Preservation Act of 1995, 21 Medicare program (traditional) accountability for, 29, 45 dispute resolution process, 301-302 enrollment, 11-12; see also Beneficiaries, Medicare expenditures, 1, 3-4, 11, 12, 24, 26 fraud and abuse, 7-8, 37-38 gaps in coverage, 12-13 HCFA restructuring activities, 22-23 overview of requirements, 11-13 Part A, 12 Part B, 12, 13, 31 recommendations, 83-84 reform strategies, 2, 75-79; see also Legislation and risk selection, 45-46 standards, 45 viability of, 45-46, 82-83 Medicare Risk Contract Program. See also Risk contract HMOs enrollments, 2 legislation (proposed), see Balanced Budget Act of 1995 Medicare SELECT, 15 Medigap insurance, 9, 13, 14, 69, 70, 84, 87-89, 97, 98, 100 Mental health treatment, 165, 171 Mental illness, 212 Minnesota community integrated service networks, 309 HMO oversight, 154, 307, 308, 309 outcomes research, 311 Minnesota Employees Insurance Program, 49-50, 149; see also Southern California Edison health program Minnesota Health Data Institute, 251-252, 260, 293-294 Model HMO Act of the National Association of Insurance Commissioners, 306, 317 Model programs. See also specific corporations and organizations accountability requirements, 48 benefit designs, 47 information provided to beneficiaries, 47, 48 negotiation of costs, 46 purchasing coalitions and cooperatives, 46-47 for retirees, 49-50 thresholds of participation in plans, 46 Modern Maturity,239, 240 Montana, 262 Myocardial infarction, acute, 209

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--> N National Academy of Aging, 50 n.11 National Academy of Social Insurance, 83 National Association of Insurance Commissioners, 306, 313, 317 National Association of Managed Care Regulators, 310 National Committee for Quality Assurance (NCQA), 5, 34, 41 n.2, 73, 90, 103, 144, 153, 156, 167, 169, 245, 274-275, 277, 284, 310-311, 315, 320 National Council on the Aging, 155 National Research Corporation, 201 Network Design Group, 301, 302, 304 New Mexico, 262 New York, 52, 196, 296 n.2 Nonprofit organizations, information distribution by, 65, 65, 177-178, 249, 251-252, 257-258, 260-261 North Carolina, 259 Nursing homes, 52, 60, 69, 71 Nynex, 250 O Office of the Inspector General, 67-68, 279, 295, 310 Ohio, 311 Ombudspersons, 42-43, 94, 154, 316, 350 Omnibus Budget Reconciliation Act of 1985, 326 Omnibus Budget Reconciliation Act of 1987, 326 Omnibus Budget Reconciliation Act of 1990, 315, 326, 335 Omnibus Budget Reconciliation Act of 1995 accreditation requirements, 156 advantages and disadvantages, 146-147 contracting standards, 305 DHHS responsibilities under, 145 enrollment requirements, 151 as a framework for reform, 5, 33 goals for Medicare, 137-138 improvements needed in, 78-79 information requirements, 312 n.4 market structure under, 138, 142, 146-147 potential impact of, 336-337 provisions eliminated from, 21 quality assurance requirements, 143, 225 "report card," on, 75-79 On Lok Senior Health Services, 220 Oregon, 262 Organ transplants, 165 Out-of-area service, 166 Outcomes of care acute myocardial infarction, 209 diabetes, 331-332 home health care and, 298 n.3 mental illness, 212 monitoring and evaluation methods, 270, 310-311 referrals to specialists and, 209 research, 155-156 vulnerable individuals in managed care, 53, 208-213 P Pacific Business Group on Health, 347 Parade, 239 Patient Right to Know Act, 62 n.30 Patient satisfaction. See Satisfaction with managed care Peer review organizations, 292, 304, 305, 316, 331-332 Pennsylvania, 307 Perfect competition theory, 140 Performance assessment measures, 144, 182, 224-225 complaint rates, 154 data, 74, 346-347 enforcement measures, 154, 224 incentives, 182 policy issues, 193-194 professionalism and, 10, 44-45, 58, 61, 84, 100, 101, 140-141, 144-145 report cards, 49, 144, 145, 151, 167-168 standards, 169, 187 Physical adaptation of homes, 52

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--> Physical examinations, annual, 16, 20 Physician Payment Review Commission (PPRC), 5, 30 n.4, 34, 67, 83, 98 n.5, 105 Physicians anticriticism clauses and gag rules, 10, 62, 100 choice of, 20-21, 27, 65, 81, 89, 169, 189, 277, 278, 296 conflicts of interest, 10, 62, 84, 100, 142 continuity of care, 68, 211 directories/lists, 49, 62, 298, 314-315 education of, 171 importance of communication to, 271 out-of-plan, 302 payment incentives, 10, 58, 61, 84, 100, 101, 228, 321 professional judgments on care, 44-45 recommendations for, 10, 100-101 risk selection by, 46 sources of patient dissatisfaction, 300, 302-303 Physicians Health Service, 176 Picker Institute for Patient-Centered Care, 66, 271, 272-274, 275-276, 283, 284 PlanSource (Kentucky), 149 Point-of-service option, 15, 21, 86, 146, 161, 168, 169, 170, 176, 330 Population-based medicine, 53, 216 Portability of coverage, 60, 61, 85 Preferred provider organizations, 40, 308 Premiums and cost sharing strategies administrative fee, 184-185 employer's contribution, 162, 166, 169 fee-for-service, 166-167 negotiation of, 49 performance credits, 166 policy issues, 193 and purchasing decisions, 39, 172 Prescription drug coverage, 16, 20, 60 Prevention,239 Price Waterhouse, 286 Primary care long-term nursing home populations, 52 model for chronic care illness, 218-219 quality of, 210 Private health care sector consumer education by, 252-253, 259, 262 employer expenditures, 2 health plan choices, 40 structural changes, 1, 16, 18 Private sector employees number of plan choices, 148 Professionals/Professionalism. See Health care professionals Program of All-Inclusive Care for the Elderly/On Lok projects, 220 Progressive Policy Institute, 154-155 Prospective Payment Assessment Commission (ProPAC), 83, 320 Provider lists, 49, 62, 189, 298, 314-315 Provider service networks, 21 Provider-sponsored organizations, 305, 308-309 Prudential HealthCare System, 164 Public accountability committee focus, 6-7, 8, 36-37 conceptual framework, 34-35 consumer role, 40, 42-43, 153-155 context, 24, 138-141 defined, 30-31 elements of, 31-32 government role, 10, 40, 41-42, 147-153 key issues, 43-45 literature on, 34 professional influences, 40, 43, 155-157 recommendations, 10 scope of, 142-143 structuring, 39-46, 144-145 Public agencies. See also specific agencies information distribution through, 184-185, 245-248, 253-254, 255-257, 258-259, 261-262, 334 Public oversight. See also Regulation of managed care organizations; Standards and standard setting federal contracting standards, 304-305

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--> state regulation of managed care organizations, 305-311 Purchasing of plans by associations, 176 consumer cooperatives approach, 152-153 competitive bidding process, 150, 152-153, 160, 164, 168-169, 183-184 employer alliances, 147, 148-149 federal government role, 150, 151-153 information sources, 334 Medicare managed care organizations, 77 negotiations, 172, 183-184, 345 by nonfederal public employers, 149-150 premiums and, 39 recommendations, 83 by state-chartered cooperatives, 153 strategies, 151-153, 164, 172, 175 by voluntary cooperatives, 46-47, 71, 154-155, 179-182 Q Qualified Medicare beneficiaries, 13 program, 205 Quality assurance and improvement, 103, 105, 143, 144, 175, 224-225, 270, 310, 331-332. See also Performance Quality Assurance Reform Initiative (QARI), 310-311 Quality of care. See also Satisfaction with managed care consumer definitions of, 271-274 data collection on, 74, 347-348 defined, 3 n.2, 52, 273-274 external review, 224-225 indicators, 73 information wanted by consumers, 58-62, 274-275 patient reports, 271 report cards, 49, 57, 61, 74, 347 standard setting and, 69-70, 103, 105 standardization and, 69-70 R RAND Health Insurance Experiment, 212-213 medical outcomes study, 212 Recommendations. See also Research recommendations access for underserved populations, 105-107 accountability, 10 administration of Medicare choices, 10, 107-110 appeals and grievance procedures, 9 choice of health plans, 9, 81-82 conditions of participation, 81-82, 101, 102-103, 104 education-oriented organizations, 95-96 enrollment/disenrollment guidelines, 9, 84-86 funding, 96-97 grievance and appeal procedures, 84, 86-87 HCFA role, 83-84 information infrastructure, 9-10, 89, 90-91, 94-97 information needs for informed choice, 89-91, 92-93, 282-286 marketing rules, 9, 84, 87-89 physician professionalism, 10, 100-101 quality assurance, 103, 105 risk selection measurement, 83 timing of marketing, 10 traditional Medicare program, 9, 83-84 standardization of benefit plans, 98-100 Reconciliation bill. See Omnibus Budget Reconciliation Act of 1995 Referrals to specialists, 53, 61, 65, 66, 101, 209, 298, 300, 307, 314-315 Regulation of managed care organizations. See also Legislation; specific statutes level of government authority, 317-318

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--> and satisfaction with care, 313-317 by states, 74 types of organizations, 313 Rehabilitation services, 71, 165, 298-299 Research recommendations clinical effectiveness and outcomes, 155-156 communication of information, 321-322 consumer protection standards, 322 enrollee satisfaction research, 319-321 ICA programs, 321-322 Research Triangle Institute, 244-245, 254, 256, 278, 320, 336 Respite care, 52 Retirees dissemination of information to, 280 education by employers, 95, 169-170, 249-250 information needs of, 278 Medicare services, 330 structuring choice for, 49-50, 163, 165-166, 168 Retirement Living Forum, 63, 258 Risk contract HMOs beneficiary characteristics, 201 benefits, 16, 20 costs, 52, 53 enrollees, 4, 16, 18-19, 51, 196, 328 expenditures, 208 experience of Medicare beneficiaries in, 51-54 geographic distribution, 16, 17, 52 incentives for enrollment, 16, 20 outcomes, 53, 208 point-of-service option, 15 profits, 15, 61 quality of care, 52-53, 69 n.38 satisfaction with care, 147, 293-295 service delivery for seniors, 52, 217-218 standards for entry, 41, 304-305 Risk contracts/risk plans. See Private health care sector Risk selection AAPCC methodology and, 227-228 adverse, 26-27, 45-46, 78, 146, 162, 176 by beneficiaries, 78 benefit plan standardization and, 184 conditions of participation and, 82 defined, 86-87 in FEHBP program, 146 and grievances, 86-87 importance, 7, 37, 84 measurement and adjustment, 83, 146, 161 n.1 number of plans offered and, 162 physician financial incentives and, 84 purchasing approach and, 152 S Sailor, 257 Satisfaction with managed care. See also Disenrollment; Quality of care assessment of, 186, 189, 272 consumer complaints, 296-299 with costs, 53, 65, 213 data sources, 170, 319-321 disenrollment and, 67-68, 293, 294 education of consumers and, 57-58, 66-67, 85, 299-300, 314-315 focus group studies, 66, 272, 273, 274, 276-277, 295-296 health status and, 213-214 HMO enrollees, 147, 292-293, 320-321 information accuracy and usability and, 57-58, 314-315 information needs of consumers, 61, 274-275 Medicare HMO enrollee surveys, 293-295 overcoming barriers to, 313-317 overview, 65-67 with physician-patient interactions, 52-53 with quality of care, 52-53 rating system, 66-67 research recommendations, 319-320 sources of dissatisfaction, 65, 291-300 standardization of data, 224 survey results, 65-66, 67, 213-214

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--> Securities and Exchange Commission, 156 SeniorCare Options Program, 221-222 Senior citizens' groups, 42-43, 60 SeniorNet, 63, 257-258 Service delivery capitation payments and, 45 case management, 52, 222-223 Cooperative Health Care Clinic, 219-221 geriatricians, 217 information needs on, 61-62 integration of acute and long-term-care services, 220-221 Medicare requirements, 329-330 new arrangements, 308-309 primary care model for chronic illness, 218-219 risk contract HMO practices, 52, 217-218 SeniorCare options program, 221-222 state regulation of, 308-309, 317 Setting Priorities for Retirement Years (SPRY) Foundation, 244, 258, 259 Sierra Health Services, 221 Skilled nursing services, 12 Social HMOs, 15, 220-221 Social Security Act, 327 Social Security Administration, 244, 246, 248, 256, 258-259, 261, 302, 332 Social Security income, 205 South Carolina, 262 South Dakota, 307 Southern California Edison health program beneficiaries, 168 educating employees on, 169-170, 188, 189, 190, 191, 194 enrollment, 169 improvements anticipated, 170-171 performance standards, 169 process for choosing plans, 168-169 types of plans, 168 Southern Living,239 Standardization of benefit plans, 47, 49, 69-70, 73, 98, 99, 161, 184, 186, 192, 344-345 consumer satisfaction data, 224 of surveys, 91 Standards and standards setting. See also Conditions of participation for access to care, 316-317 Balanced Budget Act of 1995, 79 credentialing, 106 enforcement of, 305 for entry, 41, 150-151, 304-305 50-50 rule, 41, 51-52, 69 information, 317 national, 223-224 performance, 169, 187 and quality of care, 69, 316-317 solvency, 313 state, 311 State regulation federal partnerships, 74-75, 98, 100, 310, 317-318 HMOs, 305-308 insurance commissions, 281 licensure, 318 Medicaid managed care plans, 309-311 PPOs, 308 service delivery arrangements, 308-309 Stocker, Michael, 153 Strategic Directions, 241 Substance abuse treatment, 165 Support programs, 52 Surveys. See also individual surveys communications preferences of beneficiaries, 239-240 exit, 349 health status, 200-201 HMO enrollees, 292-293 Medicare HMO enrollees, 293-295 quality of care, 347-348, 349 satisfaction with care, 65-66, 67, 189, 213-214, 319-320 standardization, 91 Symposium organization, 36 participants, 34 T Tax Equity and Financial Responsibility Act, 13, 326 Telemarketing Act of 1994, 254

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--> Texas Insurance Purchasing Association, 149 The Alliance (Denver, Colorado), 179-182 The HMO Group, 164 Geriatric Interest Group, 216 Towers Perrin, 250, 256 Trust issue, 9, 44, 60, 64, 90-91 U UltraLink, 164, 250 Union Carbide, 250 United Seniors Health Cooperative, 61, 65, 262 University of Minnesota, 222 U.S. Department of Defense, 73, 150 U.S. Department of Health and Human Services, 22, 78, 143, 145, 279, 305, 310, 327 U.S. General Accounting Office, 34, 35, 69, 297, 305, 310, 317 U.S. Healthcare, 62 n.30, 164 USHC Development Corporation, 262 Utilization of health care fee for service and, 26 financial incentives to limit, 26 review, 270 self-assessed health and, 26 by vulnerable populations, 203, 214-215 V Vouchers, 42 W Waiting time for appointments, 66, 300, 302-303, 307 Wal-Mart, 259 Washington State, 149, 311 Washington, D.C., 306 Wennberg, John E., 44 n.4 Wheaton Regional Public Library (Montgomery County, Maryland), 248 Wisconsin Employee Trust Fund benefit plan standardization, 184, 192 consumer education, 184-185 information dissemination, 185-186 price negotiation, 183-184 structure, 183 X Xerox HealthLink HMOs accountability requirements, 48 benchmark pricing, 166-167 benefit plan design, 47, 164-166, 192 consumer information, 48, 167, 194 managers, 164, 191 objectives, 163 performance reporting, 167-168 Y Yankee magazine, 239