Improving Accountability in Medicare Managed Care:...

Front Cover
Charles E. Grassley
DIANE Publishing, 1998 - 135 pages
Focuses on how Congress & the Administration can provide better information to Medicare beneficiaries when they are trying to select the right health plan to meet their health care needs. Contains statements from U.S. Senate Committee on Aging members as well as testimony from the Medicare Rights Center in New York City, the Institute of Medicine in Stanford, CA, the Health Benefits Service of the California Public Employees Retirement System, & a Medicare beneficiary. Includes General Accounting Office responses to Senate questions on the operations of the Health Care Financing Administration.

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Page 19 - A, like-minded purchasers, and beneficiaries in order to hold plans and providers accountable for the care they deliver. HCFA and the Agency for Health Care Policy Research (AHCPR) have been active in promoting research to identify these measures. With such measurements in hand, HCFA and the public will be able to objectively compare managed care to itself and to fee-for-service, and to determine whether managed care is living up to its potential to improve the quality of care. However, more research...
Page 112 - ... reasonable degree defined by the federal government so as not to divide metropolitan areas or counties except when natural barriers or other conditions divide service areas; • provide a user-friendly, well-communicated, and responsive appeals and grievance process and allow retroactive disenrollment of beneficiaries who are determined by a fair and appropriate process to have misunderstood the implications of their choice and who have suffered serious financial or other consequences; • meet...
Page 100 - ... plans have been discontinued because of their high premiums, their noncompetitive benefits, and adverse risk selection. Within this environment, special challenges exist for the future viability of the traditional Medicare program. Constraints on Medicare spending are adding new urgency to managing the costs of care delivered in the traditional Medicare program. Maintaining traditional Medicare as an option is likely to be difficult and could require additional costs to government. The committee...
Page 114 - ... The committee believes that these growing choice management functions would benefit from an organizational identity with the stature to facilitate recruitment of the needed leadership and staff and to build public trust. For that reason the committee recommends that serious consideration be given to establishing a new function along the lines of a Medicare Market Board, Commission, or Council that would include an advisory committee with key stakeholders (ie, purchasers, providers, and consumers)....
Page 8 - HCFA's comparability charts so that beneficiaries have important information about particular plans Health Insurance Advisory Program The Health Insurance Advisory Program (HIA) is designed to develop and strengthen the capability of states to provide Medicare beneficiaries with information, counseling, and assistance on adequate and appropriate health insurance coverage.
Page 103 - This can be achieved through interplan reciprocity or point-of-service options. Grievance and Appeals Procedures Findings The current Medicare appeals process has been shown to be slow and not adequately advertised by HCFA or health plans. Furthermore, the current appeals process is tailored more to reviewing whether a service should be reimbursed by Medicare or a health plan and less on the important issue of whether a needed service was denied. In a competitive environment, to attain better risk...
Page 22 - Under Federal law, aged individuals have a once in a life-time opportunity to select the Medigap plan of their choice when they first join Medicare at age 65; individuals who become eligible for Medicare because of a disability or end-stage renal disease beneficiaries have no such choice. If a beneficiary enrolls in a managed care plan and is later dissatisfied, he or she may not have the opportunity to select the Medigap plan of his or her choice; for example, drug coverage may be unavailable due...
Page 98 - Tom J. Elkin Independent Health Care Consultant Sacramento, CA Allen Feezor, MA. Vice President for Insurance and Managed Care Programs East Carolina University Medical Center Pitt County Memorial Hospital Greenville. NC James P. Firman, MBA, Ed.D. President and Chief Executive Officer National Council on the Aging Washington, DC Sandra Harmon- Weiss, MD Vice President and Medical Director US Healthcare Blue Bell, PA Risa J.
Page 110 - Findings The committee recognizes that physicians' advice to beneficiaries is a quintessential part of ensuring informed choice. Because of the inherently personal nature of the physician-patient relationship and its special importance to elderly patients, the committee is concerned about the increasing restrictions on physicians (and the potential conflict of interest of physicians) when they act in their professional role as advocates for their patients and carry out their contractual responsibilities...
Page 9 - ... reviews involving service denials and terminations, and improved health plan accountability on the results of appeals and grievances. However, we cannot afford to be complacent in the face of recently publicized concerns, and streamlining the appeals process is one of our highest priorities. Unrestricted Medical Communication: The Medicare statute requires that contracting health plans must make all covered services available and accessible to each beneficiary as determined by the individual's...

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