Disabled Medicare Beneficiaries in HMOs

Health Affairs

Volumn 16, Issue 5, 1997, Pages 149-162

  Gold, Marsha ^a   Nelson, Lyle ^a   Brown, Randall ^a   Ciemnecki, Anne ^a   Aizer, Anna ^a   Docteur, Elizabeth ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

ADULT; ARTICLE; DISABLED PERSON; ECONOMICS; FEMALE; HEALTH CARE DELIVERY; HEALTH MAINTENANCE ORGANIZATION; HUMAN; MALE; MEDICARE; MIDDLE AGED; PATIENT SATISFACTION; SOCIOECONOMICS; STATISTICS; UNITED STATES; UTILIZATION REVIEW;

ADULT; DISABLED PERSONS; FEMALE; HEALTH MAINTENANCE ORGANIZATIONS; HEALTH SERVICES ACCESSIBILITY; HUMANS; MALE; MEDICARE; MIDDLE AGED; PATIENT SATISFACTION; SOCIOECONOMIC FACTORS; UNITED STATES;

EID: 0345982190     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.16.5.149     Document Type: Article

References (25)

1. See M.H. Davis and E. O'Brien, "Profile of Persons with Disabilities in Medicare and Medicaid," Health Care Financing Review (Summer 1996): 179-211; and M.L. Rosenbach, "Access and Satisfaction with the Disabled Medicare Population," Health Care Financing Review (Winter 1995): 147-167.
2. See M.H. Davis and E. O'Brien, "Profile of Persons with Disabilities in Medicare and Medicaid," Health Care Financing Review (Summer 1996): 179-211; and M.L. Rosenbach, "Access and Satisfaction with the Disabled Medicare Population," Health Care Financing Review (Winter 1995): 147-167.
3. See R.S. Brown et al., "Do Health Maintenance Organizations Work for Medicare?" Health Care Financing Review 15, no. 1, (1993): 7-24; and J. Ware et al., "Differences in Four-Year Health Outcomes for Elderly and Poor, Chronically-Ill Patients Treated in HMO and Fee-for-Service Systems," Journal of the American Medical Association 276, no. 13 (1996): 1039-1047.
4. See R.S. Brown et al., "Do Health Maintenance Organizations Work for Medicare?" Health Care Financing Review 15, no. 1, (1993): 7-24; and J. Ware et al., "Differences in Four-Year Health Outcomes for Elderly and Poor, Chronically-Ill Patients Treated in HMO and Fee-for-Service Systems," Journal of the American Medical Association 276, no. 13 (1996): 1039-1047.
5. HMO estimates calculated from the Group Health Plan (GHP) file obtained from the Health Care Financing Administration (HCFA) to reflect those enrolled in a risk HMO for at least two months between 1 March 1995 and 1 March 1996. Data for 1993 based on Davis and O'Brien, "Profile of Persons."
6. A more detailed description of the sample design and survey instrument is given in L. Nelson et al., Access to Care in Medicare Managed Care: Results from a 1996 Survey of Enrollees and Disenrollees, Selected External Research Series Number 7 (Washington: Physician Payment Review Commission, November 1996). See also L. Nelson et al., "Access to Care in Medicare HMOs, 1996," Health Affairs (March/April 1997): 148-156.
7. A more detailed description of the sample design and survey instrument is given in L. Nelson et al., Access to Care in Medicare Managed Care: Results from a 1996 Survey of Enrollees and Disenrollees, Selected External Research Series Number 7 (Washington: Physician Payment Review Commission, November 1996). See also L. Nelson et al., "Access to Care in Medicare HMOs, 1996," Health Affairs (March/April 1997): 148-156.
8. Ibid. We also oversampled plan switchers and those enrolled in plans with fewer than 100,000 Medicare enrollees. See Nelson et al., Access to Care in Medicare Managed Care for details.
9. These consultants included Lucy Fisher of the Group Health Foundation, Marshall McBean of the University of Minnesota, Sheldon Retchin of the Medical College of Virginia, and Shoshanna Sofaer of The George Washington University. For a description of the framework and its rationale, see E. Docteur, D. Colby, and M. Gold, "Shifting the Paradigm: Monitoring Access in Medicare Managed Care," Health Care Financing Review (Summer 1996): 5-21.
10. The GHP file used as the sample frame does not include telephone numbers. Hence, researchers must use a variety of external techniques for locating persons by telephone, including look-up services and mailed responses requesting a reply to an 800 number. There were no statistically significant differences between responders and nonresponders in age distribution, sex, or whether elderly beneficiaries had ever been entitled to Medicare because of a disability. Nonresponders were more likely than responders to be African American, institutionalized, and covered by Medicaid.
11. The under-age-sixty-five disabled population was only slightly more likely than beneficiaries ages sixty-five to eighty-four to need a proxy to respond for them (6.8 percent versus 5.3 percent). In general, beneficiaries who responded by proxy were more likely than other beneficiaries to be age eighty-five or older, covered by Medicaid, and institutionalized.
12. HCFA is now revising the MCBS to enlarge the HMO sample and address content issues that limit the comparability of responses between those in HMOs and those in fee-for-service.
13. A.M. Pope and A.R. Tarlov, eds., Disability in America: Towards a National Agenda for Prevention (Washington: National Academy Press, 1991); Davis and O'Brien, "Profile of Persons with Disabilities;" and Rosenbach, "Access and Satisfaction."
14. A.M. Pope and A.R. Tarlov, eds., Disability in America: Towards a National Agenda for Prevention (Washington: National Academy Press, 1991); Davis and O'Brien, "Profile of Persons with Disabilities;" and Rosenbach, "Access and Satisfaction."
15. A.M. Pope and A.R. Tarlov, eds., Disability in America: Towards a National Agenda for Prevention (Washington: National Academy Press, 1991); Davis and O'Brien, "Profile of Persons with Disabilities;" and Rosenbach, "Access and Satisfaction."
16. See 1994 Data Compendium (Baltimore: Health Care Financing Administration, March 1994).
17. Davis and O'Brien, "Profile of Persons with Disabilities." Once persons reach age sixty-five, they are included in the HCFA count of covered elderly. Six percent of the elderly in Medicare HMOs we surveyed were originally eligible for Medicare because of disability.
18. Baseline data on demographic, insurance, health status, and access measures were collected in this first round of interviews. See Rosenbach, "Access and Satisfaction."
19. Information on Medicaid buy-in status for those we surveyed was obtained from the GHP file. Thus, the survey does not fully measure those who are dually eligible for Medicaid. Nationally, about 20 percent of those who are dually eligible for Medicare and Medicaid are not buy-ins.
20. Among the rest, respiratory conditions accounted for 5 percent of the sample, vision problems 4 percent of the sample, and digestive system problems and mental retardation 3 percent each. Of the remainder, 9 percent have a variety of conditions, and information is not available for 5 percent.
21. These estimates are from the GHP file, which is a census of all risk enrollees. New enrollees were in a risk plan 1 March 1996 but not 1 March 1995 or at any other point during that year. Disenrollees to fee-for-service were not enrolled in a risk plan 1 March 1996 but were enrolled for at least two months during the previous twelve months. All others in our sample were either continuously enrolled in the same Medicare risk plan throughout the year or had switched from one to another.
22. Because the disabled were more likely than the elderly to be new enrollees than continuing enrollees, we also computed an adjusted rate for the elderly that used weights based on the enrollment status mix of the disabled and found that it had no effect.
23. M. Rosenbach and J. Huser, "Utilization, Access, and Satisfaction with Care among Noninstitutionalized Medicare Beneficiaries: A Baseline Analysis," in Health Care Financing Administration: Third Annual Report to Congress on Monitoring Utilization and Access to Service for Medicare Beneficiaries under Physician Payment Reform (Washington: HCFA, 1993).
24. Again, because of differences in the design of the MCBS and the MPR/PPRC surveys, it is difficult to make HMO/fee-for-service comparisons. Our analysis of the HMO data collected in the MPR/PPRC survey involves measures computed from a series of questions about specific access problems and thus is likely to yield more reported problems than the single global fee-for-service item used in the MCBS.
25. The current Medicare capitation rate-setting system adjusts payments for risk-based HMOs to account for differences in the age, sex, Medicaid, and institutional status of disabled beneficiaries. Among those not institutionalized, rates are con siderably lower for those not enrolled in Medicaid and increase about twofold between the youngest age group (under age thirty-five) and the oldest age group (ages sixty to sixty-four) for the disabled They then drop sharply for elderly beneficiaries ages sixty-five to sixty-nine and increase at a slower rate from there (Rates for disabled persons who are institutionalized decrease with age.)