Pope G, Greenwald LM, Kautter J, Olmstead E, Mobley L; AcademyHealth. Meeting (2005 : Boston, Mass.).
Abstr AcademyHealth Meet. 2005; 22: abstract no. 3801.
RTI, International, Division for Health Services and Social Policy Research, 411 Waverley Oaks Rd, Suite 330, Waltham, MA 02452-8414 Tel. 781-788-8100 ext 134 Fax
RESEARCH OBJECTIVE: To examine how PPOs have operated so far under the Medicare PPO demonstration, including PPO availability and market entry; premiums, benefits and beneficiary cost sharing; and enrollment, market share, enrollee characteristics, and disenrollment to date. STUDY DESIGN: This research analyzed descriptive data from counties in which the 35 Medicare PPO demonstration plans currently operate. The primary purpose of the analysis was to compare PPO and competing coordinated care plans (CCPs). Findings were generated primarily from the Medicare Health Plan Management System (HPMS) maintained by CMS. HPMS collects service area, premium, benefit, cost sharing, out-of-pocket cost, physician network size, and other information for most Medicare private plans. In addition, Medicare's Enrollment Database, which records monthly health plan enrollment status and various demographic characteristics for all Medicare beneficiaries, was used. Finally, we obtained and analyzed CMS Hierarchical Coexisting Conditions (CMS-HCC) risk scores measuring beneficiary health status. POPULATION STUDIED: Medicare beneficiaries PRINCIPAL FINDINGS: Demonstration PPOs are widely, but unevenly, available. They are less likely than coordinated care plans to be available in rural areas. PPOs have located mostly where other CCPs are offered, but have increased the choice of such plans for Medicare beneficiaries. Higher demonstration county payment rates did not increase demonstration PPO availability; the rate of PPO entry in counties where demonstration payment was higher than the regular M+C amount was almost the same as in counties where it was not about 7 percent in both types of counties. When comparing the benefit packages and out of pocket costs, we found that demonstration PPO monthly premiums are generally higher than competing CCP options, but lower than the most popular Medigap plan. On average, PPOs charge monthly premiums more than twice as much as competing CCPs, $76 versus $29. Demonstration PPOs are more likely than competing CCPs to provide some coverage for prescription drugs; but among plans with a drug benefit, PPO coverage is less generous on average. Finally, enrollment in the demonstration PPOs have been somewhat lower than plans expectations, but steadily increasing. Of PPO enrollees, 42 percent were previously enrolled in FFS Medicare, 43 percent in a CCP, and 15 percent are recent enrollees in the Medicare program. The demographic and health status characteristics of PPO enrollees are similar to those of recent enrollees in competing CCPs. CONCLUSIONS: The Medicare PPO demonstration has succeeded in making a new managed care option available to a significant proportion of Medicare beneficiaries, though mostly in urban or near-urban areas where other managed care options already exist. The premiums of plans offered by the demonstration PPOs tend to be more costly than competing CCPs, but less costly than popular Medigap options. PPOs may represent a reasonable mid-point product for beneficiaries. But higher monthly premium cost of PPOs seems to be an important factor limiting PPO enrollment relative to HMOs. The new regional PPOs authorized by MMA beginning in 2006 may address some of the limitations of the demonstration PPOs. IMPLICATIONS FOR POLICY, DELIVERY OR PRACTICE: PPOs are a key part of the MMA MA program and will therefore be important in future delivery of Medicare services.
Publication Types:
Keywords:
- Cost Sharing
- Costs and Cost Analysis
- Fees and Charges
- Health Expenditures
- Managed Care Programs
- Medicare
- Preferred Provider Organizations
- economics
- hsrmtgs
UI: 103623264
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