Medicare+Choice Appeal Procedures: Reconciling Due Process Rights and Cost Containment

1999 ◽  
Vol 25 (1) ◽  
pp. 61-116
Author(s):  
Jennifer E. Gladieux
Keyword(s):  
Due Process ◽  
Care Delivery ◽  
Federal Budget ◽  
Health Maintenance Organizations ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Balanced Budget Act ◽  
Health Maintenance ◽  
Preferred Provider Organizations ◽  
Delivery Options

By signing the Balanced Budget Act of 1997 (BBA) on August 5, 1997, President Clinton made the most significant changes to Medicare, since its inception in 1965, by adopting market-driven reforms in an effort to balance the federal budget. One of the most significant Medicare reforms in the BBA was the creation of the Medicare+Choice program that provides Medicare beneficiaries access to a wide array of private health plan choices as well as traditional fee-for-service (FFS) Medicare. In addition, Medicare+Choice enables Medicare to further utilize delivery innovations, including preferred provider organizations (PPOs), openended health maintenance organizations (HMOs), point-of-service plans, provider sponsored organizations (PSOs), integrated delivery systems (IDSs) and primary care case management, that have helped the private sector contain costs and expand health care delivery options.

scholarly journals CMS Payments Necessary to Support HMO Participation in Medicare Managed Care

2002 ◽  
Vol 5 (1) ◽  
Author(s):  
John Cawley ◽  
Michael Chernew ◽  
Catherine McLaughlin
Keyword(s):  
Managed Care ◽  
Cost Effective ◽  
Health Maintenance Organizations ◽  
Medicare Beneficiaries ◽  
Balanced Budget Act ◽  
Health Maintenance ◽  
Relative Disadvantage ◽  
Balanced Budget ◽  
Normative Statement ◽  
Capitation Payments

In recent years, many health maintenance organizations (HMOs)have exited the market for Medicare managed care; since 1998, the number of participating plans has fallen from 346 to 174. As a result of this reduced participation by HMOs, hundreds of thousands of Medicare beneficiaries have been involuntarily disenrolled from the program at the end of each year from 1998 to 2001.This paper estimates the Centers for Medicare and Medicaid Services (CMS) capitation payments that are necessary to support the participation of various numbers of HMOs in Medicare managed care per county market. This paper does not make a normative statement about how many HMOs should be supported in this program; rather, it makes a positive statement about the levels of payment necessary to support various numbers of HMOs.The identification strategy is to observe how the number of participating HMOs varies over counties and time in response to CMS payment, while controlling for estimated costs. This paper studies the period 1993-2001 and focuses in particular on the variation in payment, independent of costs, that occurred as a result of the Balanced Budget Act of 1997, which dramatically changed the way that HMOs are paid in this program. In light of the fact that it may not be cost-effective for CMS to support HMO participation in relatively rural or unpopulated counties, the sample used in this paper is limited to the 60 percent of U.S. counties with the largest populations of Medicare beneficiaries.The ordered probit results presented in this paper indicate that, to support one Medicare HMO in 2001 in half of the counties in the sample, CMS would have to pay $682.08 per average enrollee per month in the marginal county. To support one Medicare HMO in 2001 in every county in the sample, CMS would need to pay $1,008.25 per enrollee per month in the maximum-payment county. For comparison, the maximum monthly payment paid by CMS to any county in 2001 was $833.55.This paper finds that 79.3 percent of counties in the sample received a CMS payment in 2001 that was less than what was necessary to support a single HMO in Medicare managed care. Compared to those counties that received a payment exceeding the estimated threshold for HMO participation, these counties are, on average, more rural and less populated, with citizens who are less wealthy and less educated. The relative disadvantage of rural and unpopulated counties persists three years after the Balanced Budget Act of 1997, designed in part to eliminate such disparities, took effect.

Longitudinal Analysis of Patient Satisfaction among Medicare Beneficiaries in Different Models of Health Maintenance Organizations and Fee-for-Service Care

1992 ◽  
Vol 5 (3) ◽  
pp. 198-206 ◽  
Author(s):  
Myde Boles ◽  
Thomas T. H. Wan
Keyword(s):  
Patient Satisfaction ◽  
Health Maintenance Organizations ◽  
Independent Practice ◽  
Group Model ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Health Maintenance ◽  
Different Types ◽  
One Year ◽  
Independent Practice Association

Based on a randomly selected nationwide sample of Medicare beneficiaries, this study analyzes changes in patient satisfaction over a one year period for beneficiaries receiving care in a variety of delivery settings: fee for service, group model HMO, staff model HMO, and Independent Practice Association model HMO. The findings reveal the patient satisfaction changes significantly over a one year period, from lower levels of satisfaction to higher levels of satisfaction. The primary explanation for this change in satisfaction is a decline in health status over the same one year period. Additional differences in satisfaction with care were observed for Medicare beneficiaries served by different types of delivery settings with varying degrees of utilization controls.

Determinants of total end-of-life healthcare costs of Medicare beneficiaries: A quantile regression forests analysis

2021 ◽  
Author(s):  
Lihua Li ◽  
Liangyuan Hu ◽  
Jiayi Ji ◽  
Karen Mckendrick ◽  
Jaison Moreno ◽  
...  
Keyword(s):  
Quantile Regression ◽  
End Of Life ◽  
Healthcare Costs ◽  
Health Maintenance Organizations ◽  
Medicare Beneficiaries ◽  
Health Maintenance ◽  
Regional Characteristics ◽  
Hospital Referral Region ◽  
High Quantiles ◽  
Hospital Referral

Abstract Background To identify and rank the importance of key determinants of end-of-life (EOL) healthcare costs, and to understand how the key factors impact different percentiles of the distribution of healthcare costs. Methods We applied a principled, machine learning based variable selection algorithm, using Quantile Regression Forests, to identify key determinants for predicting the 10 th (low), 50 th (median) and 90 th (high) quantiles of EOL healthcare costs, including costs paid for by Medicare, Medicaid, Medicare Health Maintenance Organizations (HMO), private HMO, and patient’s out-of-pocket expenditures. Results Our sample included 7,539 Medicare beneficiaries who died between 2002 and 2017. The 10 th, 50 th and 90 th quantiles of EOL healthcare cost are $5,244, $35,466 and $87,241 respectively. Regional characteristics, specifically, the EOL-expenditure index, a measure for regional variation in Medicare spending driven by physician practice, and the number of total specialists in the hospital referral region, were the top two influential determinants for predicting the 50 th and 90 th quantiles of EOL costs, but were not determinants of the 10 th quantile. Black race and Hispanic ethnicity were associated with lower EOL healthcare costs among decedents with lower total EOL healthcare costs but were associated with higher costs among decedents with the highest total EOL healthcare costs. Conclusions Factors associated with EOL healthcare costs varied across different percentiles of the cost distribution. Regional characteristics and decedent race/ethnicity exemplified factors that did not impact EOL costs uniformly across its distribution, suggesting the need to use a “higher-resolution” analysis for examining the association between risk factors and healthcare costs.

"DR UNNECESSARY"

PEDIATRICS ◽  
1996 ◽  
Vol 97 (2) ◽  
pp. A30-A30
Author(s):  
J. F. L.
Keyword(s):  
Managed Care ◽  
Private Practice ◽  
Psychiatric Treatment ◽  
Health Maintenance Organizations ◽  
Case Managers ◽  
Fee For Service ◽  
Health Maintenance ◽  
Insurance Costs ◽  
Treatment Plans

The old reality for many psychiatrists was a private practice filled with long-term patients who paid $100 or more for 50 minutes of talk. The new reality? Managing medication for up to 30 new patients a week for half the hourly fee—and answering to case managers who aren't even doctors. No wonder the number of U.S. medical school graduates in psychiatric residencies dropped nearly 12%—to 3909 from 4447—between 1988 and 1994. The blame—or the credit—goes to managed care, the catchall term for the revolution that has swept through both the medical and mental health care fields in recent years. Desperate to cut runaway health insurance costs, most companies have axed longstanding fee-for-service plans and instead steer employees seeking psychiatric treatment to health maintenance organizations or specialized managed-care firms. These organizations decide the type and amount of care patients receive. Psychiatrists have to get with the program—and agree to its treatment plans and fee schedules—or watch the bulk of their practices disappear. Only the rare psychiatrist can attract private patients wealthy enough to pay for traditional psychotherapy without the benefit of insurance.

A Deliberative Model of Corporate Medical Management

2000 ◽  
Vol 28 (2) ◽  
pp. 125-136
Author(s):  
Mark E. Meaney
Keyword(s):  
Managed Care ◽  
Care Delivery ◽  
Cost Savings ◽  
Health Maintenance Organizations ◽  
Health Care Delivery System ◽  
Healthcare Management ◽  
Management Tool ◽  
Ethical Challenges ◽  
Health Maintenance ◽  
Real Cost

Managed care is evolving in ways that pose unique ethical challenges to those interested in the intersection of clinical and organizational ethics. For example, Disease Management (DM) is a form of managed care that has emerged in response to chronic illness. DM is a healthcare management tool that coordinates resources across an entire health care delivery system and throughout the life cycle of chronic disease. Health Maintenance Organizations have reduced some costs in the delivery of acute care, but real cost savings will result only with greater efficiencies in the delivery of costly chronic care. DM is a systematic, population-based approach that identifies persons at risk of chronic ailment, intervenes with specific programs of care, measures clinical and other outcomes, and provides continuous quality improvement. Characterized as a movement to patient-driven services, DM involves a complex web of provider relations.

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