Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. NOTES


  1. From December 1998 to October 2001, the number of Medicare + Choice risk plans classified as group or staff models fell by 31 percent (to 74 plans), even though total enrollment in these types of plans remained essentially constant at approximately 2 million. During the same time period, the number of IPA plans fell by 57 percent to 101 plans with an enrollment in October 2001 of approximately 3.5 million.

  2. CMS was formerly known as the Health Care Financing Administration (HCFA).

  3. This restriction may be less than absolute for some Medicare managed care products. For example, point-of-service options (when they exist) provide some funding for providers not in the network but do impose higher cost sharing on such use.

  4. For example, CMS estimated that the expected value of the deductibles and copayments paid by beneficiaries in the fee-for-service system is approximately $77 per month (or about $924 per year). Also, the average 1999 costs for the widely available AARP Medigap H policy, which includes a prescription drug benefit, ranged from about $100 per month to more than $200 ($1,200 to $2,400 per year), depending on the person's state of residence.

  5. Although referred to in the text as Kaiser Colorado, the programs described refer to both the health plan and the Permanente Medical Group.

  6. An Interim Final Regulation for the Medicare + Choice Program was published on June 26, 1998, requiring plans to engage in these activities; it was derived from a recommendation contained in the Consumers Bill of Rights and Responsibilities that called for allowing persons with serious and complex illnesses to have direct access to specialists. A final regulation was issued on June 29, 2000.

  7. Stapulonis et al. (2001) provide details about the survey. In calculating the response rate, we excluded two groups of ineligible respondents: (1) those who were deceased, and (2) those sample members from Kaiser Colorado who we were precluded from interviewing because they returned a postcard asking to be excluded from the study.

  8. In a few months during this 10-month period, data were obtained from only one or two of the three case-study MCOs (Stapulonis et al. 2001). However, we have no evidence of seasonality in the treatment of hip fracture or stroke and believe that the resulting samples provide a good indication of the experiences of people with hip fracture or stroke in the three case study MCOs.

  9. We would have preferred to conduct the first interview within a month or two of the event. However, it proved to be impossible to obtain and process the sample lists from the MCOs that fast.

  10. The sample weights for our survey cause the sample to sum to the population of 15,086 beneficiaries included on the lists submitted by the three MCOs. This population was obtained as follows: 72 percent are from Keystone East, 7 percent from Aspen, and 21 percent from Kaiser Colorado. The survey subsamples contain beneficiaries in care management, of advanced age, and with a recent hip fracture or stroke.

  11. In Aspen’s case, the screening is done by the Medica Health Plan rather than by the medical group.

  12. The five basic areas of daily living are: bathing, eating, dressing, transferring from bed to a chair, and toileting.

  13. The classification of people with a prior stroke was particularly problematic in developing these groups. We included these seniors in both the group with physical impairments and the one with mental impairments, even though we did not know the precise nature of any limitations resulting from their strokes. At the same time, we excluded them, and those with a previous hip fracture, from the group of seniors with chronic conditions.

  14. The SF-36 is an instrument widely used to obtain information on functional status and other patient characteristics (Ware et al. 1994). For a discussion of the PRA, see Boult et al. (1994); and Pacala et al. (1997).

  15. To test the value added of screening, Kaiser Colorado also conducted screening at two other sites. In these sites, the screening information was entered into the members’ medical records, but no special steps were taken to encourage use of that information.

  16. This reason arose at all four case study organizations and from a number of plans that are not part of the study.

  17. One indication of Medica’s adherence to Medicare fee-for-service rules is its decision not to waive the requirement that patients have a three-day hospital stay prior to receiving coverage for skilled nursing home care. Nationwide, most Medicare managed care plans waive this rule in order to facilitate moving patients to the least-costly setting where their conditions can be treated adequately.

  18. Only 1,200 PharmD’s are board certified in pharmacotherapy nationally.

  19. Medica’s decision to not waive the 3-day rule appears to have led Aspen physicians to keep some seniors in the hospital longer than the physicians would have preferred. Aspen staff indicated that their physicians wanted to ensure that beneficiaries would have their skilled nursing stays covered by Medica which might not have been the case if the physicians had acted aggressively to move patients from the hospital to a skilled nursing facility in fewer than three days.

  20. The characteristics that predict whether a person lacks sufficient information were identified using a regression analysis that estimated the relationship between all the characteristics shown in Table II.6 and the probability that a person reported not having enough information to choose the best plan. This analysis enabled us to look at the effect of each characteristic while holding all others constant. The regression analysis included only those seniors who live in the community. Seniors who were in nursing homes at the time of the survey were asked a shorter set of questions and thus cannot be included.

  21. While the fraction who were very satisfied with provider choice varied among the MCOs, we found virtually no difference in the percentage of our sample who reported dissatisfaction with choice. Thus, the differences among MCOs pertain to the distinction between being very satisfied and somewhat satisfied.

  22. The automated system was designed to get members the first available appointment, even if that appointment was not with the member’s regular primary care physician. Furthermore, the system was understaffed early in its operation, which resulted in longer wait times for a response. Since our site visits, Kaiser Colorado has changed the system to give members a choice of the first available appointment or the first appointment with their physician.

  23. We were able to interview between 33 and 61 percent of all hip fracture and stroke cases during our sample selection period.

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