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
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
beneficiaries;
Information needs of beneficiaries
age, 198-200
with chronic health problems, 202-203
committee focus, 7
disenrollment, 54-5
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
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
rights, 332
role and responsibility, 33
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
Best practices.
See also individual case studies
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
benefit design, 344-345
cost and performance data, 346-348
customer service, 348-351
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
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
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
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
study approach, 33-38
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
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
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
by telephone, 49, 56, 64, 90, 91, 170, 182, 240, 243, 244, 250, 253 -254, 281, 282
television and radio, 238-239, 255, 263
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
enrollment process, 178
participation rules, 177
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
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
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
Cooperative Health Care Clinic, 219-221
Cost containment issues, 10, 58, 61, 68, 84, 100, 101
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
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
health status and, 214-215
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
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
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
enrolled in Medicare, 11
market segments, 240-241
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
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
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
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
premiums, 166-167
quality of care, 210
satisfaction with, 290, 293-295
self-insured, 164
and utilization, 26
viability of, 82-83
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
Foundation for Accountability, 5, 34, 73, 103, 144, 156
Frederick/Schneiders, Inc., 276
Frontier Community Health Plans, 180
G
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
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
financial review, 331
HMO monitoring processes, 35, 332-333
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
enrollee information, 173-174
participation rules, 173
provider directory, 189
structure, 171-172
Health maintenance organizations (HMOs).
See also Risk contract HMOs;
Social HMOs
accreditation requirements, 41
''best practices" research, 320-321
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 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
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
HealthPartners, 282
Healthtouch, 259
HMO Colorado, 180
Home health services, 12, 53, 60, 211-212, 298 n.3
Home inspections, 52
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
Indemnity plans, 161
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
credentialing standards, 106
disenrollment rates, 51
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
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
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
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
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
Lewin-VHI, 149-150
LIA Health Alliance, 149
Libraries, information distribution through, 248, 257
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
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
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
Massachusetts, 262
Mathematica Policy Research, Inc., 67, 208, 298 n.3
McCarran-Ferguson Act, 317
Media, focus on discord and contention, 36
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
experiences of vulnerable individuals in, 51-54, 206-215
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)
dispute resolution process, 301-302
enrollment, 11-12;
see also Beneficiaries, Medicare
expenditures, 1, 3-4, 11, 12, 24, 26
gaps in coverage, 12-13
HCFA restructuring activities, 22-23
overview of requirements, 11-13
Part A, 12
recommendations, 83-84
see also Legislation
and risk selection, 45-46
standards, 45
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
Montana, 262
Myocardial infarction, acute, 209
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
Nonprofit organizations, information distribution by, 65, 65, 177-178, 249, 251-252, 257-258, 260-261
North Carolina, 259
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
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
Physical adaptation of homes, 52
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
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
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
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
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
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
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
physician professionalism, 10, 100-101
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
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
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
point-of-service option, 15
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
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
consumer complaints, 296-299
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
Securities and Exchange Commission, 156
SeniorCare Options Program, 221-222
Senior citizens' groups, 42-43, 60
Service delivery
capitation payments and, 45
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 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
information, 317
national, 223-224
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
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
Texas Insurance Purchasing Association, 149
The Alliance (Denver, Colorado), 179-182
The HMO Group, 164
Geriatric Interest Group, 216
Trust issue, 9, 44, 60, 64, 90-91
U
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
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, 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
objectives, 163
performance reporting, 167-168
Y
Yankee magazine, 239