Unbiased Analysis of Today's Healthcare Issues

Archive for the 'Managed Care' Category

Who uses out-of-network providers?

According to a recent paper by Kyanko, Curry and Busch (2003), 8 percent of insured individuals used an out-of-network physician. Why are people using out-of-network services? The authors give the following breakdown. Approximately 40 percent of individuals using out-of-network physicians experienced involuntary out-of-network care. Whereas fifteen percent of outpatient out-of-network contacts were involuntary, almost 60 […]

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California: Mandatory Enrollment of Seniors and the Disabled into Managed Care

In 2010, CMS approved California’s “Bridge to Reform” waiver request that authorized the state to expand its mandatory managed care to seniors and people with disabilities covered by Medi-Cal.  Authorized under a Section 1115 waiver, the policy affected nearly 400,000 Medi-Cal enrollees, including 240,000 who were moved from fee-for-service into managed care between June 2011 […]

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Medicare Advantage Plan’s Response to Risk Adjustment

Medicare beneficiaries have the option to enroll in private plans to have them operate their benefits rather than use the tradiational Medicare Fee-for-services (FFS) program.  Medicare pays these private plans, known as Medicare Advantage (MA) plans, premiums based on the health status of their enrollees.   Medicare uses a risk score to measure beneficiary health status. […]

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The Start of Rationing in Medicare?

Prior authorization is a common tool that managed care organizations use to reduce patient utilization of medical services.  Some physicians believe that prior authorization creates barriers to effective care, but other commentators believe that prior authorizations can be implemented in a more efficient manner.  Either way, prior authorizations are a form of rationing care. Although […]

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Early Medical Cooperatives

In the days before health reform’s pasage, many reform proponents argued for the advent of co-operative healthcare systems or “co-ops”.  Co-ops, however, have been around for a long time before that. “In the late forties, over a hundred small rural health cooperatives were founded.  Nearly all of these were in the Southwest, fifty in Texas […]

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Employer Health Benefits in California in 2011

Each year, the California Health Care Foundation (CHCF) examines trends in employer health benefits in the state of California.  Last year, I reported on the 2010 CHCF report and now I will examine the 2011 report. Between 2010 and 2011, some things have remained the same.  Healthcare premiums are far outpacing inflation over the medium […]

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Bring Market Prices to Medicare

Medicare is a government-run insurance program.  Can policy changes be made to add competition to Medicare, maintain quality and reduce cost?  A book titled Bring Market Prices to Medicare argues that it can through a competitive bidding process. This book makes a number of sensible arguments which I review today. The main proposal of the […]

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Does California really love Managed Care?

In short, yes. California is the land of managed care. Kaiser-Permanente–the managed care poster child–owns one third of the market.  Love for managed care is not just in the private market; in 2010, over half of all Medi-Cal and more than one-third of Medicare beneficiaries were enrolled in managed care plans.  Further, California managed care […]

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McAllen’s Private Insurers spend less than El Paso’s?

For the under-65 population insured by Blue Cross, total spending per-member-year in McAllen, Texas, was 7 percent lower than in El Paso, Texas.  By contrast, Atul Gawande’s 2009 New Yorker article, which used data from theDartmouth Atlas of Health Care on variations in Medicare spending, showed that per capita spending in McAllen was 86 percent higher […]

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Medicare Managed Care vs. FFS Beneficiaries: Who receives better care?

Do Medicare beneficiaries in fee-for-service plans access better physicians than those in Medicare Managed Care (MMC) plans?  Huesch (2010) attempts to answer this question for beneficiary access to quality cardiologists.  Using data on heart patients without AMI in Florida, the authors observes the following results: “No evidence was found that Medicare payor type significantly influenced […]

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