National Academies Press: OpenBook
« Previous: L What Should Be the Basic Ground Rules for Plans Being Able to Participate in the Medicare Managed Care Market? Case Study: The California Public Employees' Retirement System
Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

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

Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

 

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

Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

 

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

Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

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

Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

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

Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

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

Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

 

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

Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

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

Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

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

Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

 

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

Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

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

Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

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

Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

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

Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

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

Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

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

Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

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

Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×
Page 353
Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×
Page 354
Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×
Page 355
Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×
Page 356
Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×
Page 357
Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×
Page 358
Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×
Page 359
Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×
Page 360
Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×
Page 361
Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×
Page 362
Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×
Page 363
Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×
Page 364
Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×
Page 365
Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×
Page 366
Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×
Page 367
Suggested Citation:"Index." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×
Page 368
Improving the Medicare Market: Adding Choice and Protections Get This Book
×
Buy Hardback | $65.00 Buy Ebook | $49.99
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

Medicare beneficiaries are rapidly moving into managed care, as attempts to restrain the growth of this costly entitlement program progress.

However, advocates for patients question whether the necessary information and structures are in place to enable Medicare consumers to select wisely among private-sector managed care options. Improving the Medicare Market examines how to give Medicare beneficiaries the same choice of health plan options enjoyed in the private sector—yet protect them as consumers and patients.

This book recommends approaches to ensuring accountability and informed purchasing for Medicare beneficiaries in an environment of broader choice and managed care—how the government should evaluate and approve plans, what role the traditional Medicare program should play, how to help to elderly understand their options, and many other practical matters.

The committee discusses the information requirements of Medicare beneficiaries and explores in detail how best to respond to their special needs. And it examines the procedures that should be developed to provide the necessary protections for the elderly in a managed care system.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    Switch between the Original Pages, where you can read the report as it appeared in print, and Text Pages for the web version, where you can highlight and search the text.

    « Back Next »
  6. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  7. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  8. ×

    View our suggested citation for this chapter.

    « Back Next »
  9. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!