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MAKING MEDICARE RESTRUCTURING WORK

F i n a l R e p o r t o f S t u d y P a n e l

o n M e d i c a r e a n d M a r k e t s

November 2003

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The Role of Private Health Plans in

Medicare : Lessons From the Past,

Looking to the Future

EXECUTIVE SUMMARY

The National Academy of Social Insurance (NASI) is a nonprofit, nonpartisan organi-zation made up of the nation’s leading experts on social insurance. Its mission is topromote understanding and informed policymaking on social insurance and related

programs through research, public education, training, and the open exchange of ideas.Social insurance encompasses broad-based systems for insuring workers and their familiesagainst economic insecurity caused by loss of income from work and the cost of health care.NASI’s scope covers social insurance such as Social Security, Medicare, workers’ compensa-tion, unemployment insurance, and related public assistance and private employee benefits.

The Academy convenes steering committees and study panels that are charged with conduct-ing research, issuing findings and, in some cases, reaching recommendations based on theiranalyses. Members of these groups are selected for their recognized expertise and with dueconsideration for the balance of disciplines and perspectives appropriate to the project.

The views expressed in this report do not represent an official position of the NationalAcademy of Social Insurance, which does not take positions on policy issues, or its funders.The report, in accordance with procedures of the Academy, has been reviewed by a commit-tee of the Board for completeness, accuracy, clarity, and objectivity.

The Academy wishes to thank the Robert Wood Johnson Foundation for its generous support of this project.

© 2003 National Academy of Social InsuranceISBN# 1-884902-40-5

Suggested Citation:

King, Kathleen M. and Mark Schlesinger, (eds.), Final Report of the Study Panel on Medicareand Markets—The Role of Private Health Plans in Medicare: Lessons from the Past, Looking tothe Future (Washington, D.C: National Academy of Social Insurance, September 2003).




November 2003




EXECUTIVE SUMMARY

ii N a t i o n a l A c a d e m y o f S o c i a l I n s u r a n c e

Kathleen M. KingStudy Director and Director of Health Security Policy

Virginia RenoVice President of Research

Reginald D. Williams, IIResearch Assistant

ContractorsNaderah Pourat, Ph.D.

University of California at Los Angeles

Project Staff

iiiT h e R o l e o f P r i v a t e H e a l t h P l a n s i n M e d i c a r e

National Academy of Social InsuranceThe Study Panel on Medicare and Markets

Mark Schlesinger,* ChairYale and Rutgers Universities

Alfred Chiplin, Jr.*Center for Medicare Advocacy

Deborah Chollet*Mathematica Policy Research, Inc.

Robert Crane*Kaiser Permanente,Institute for Health Policy

Brian DowdUniversity of Minnesota

Carroll Estes*University of California,San Francisco

Rashi Fein*Harvard University

Ann Barry FloodDartmouth University

Barbara GagelIndependent Consultant

Mark Pauly*University of Pennsylvania

Mark PetersonUniversity of California,Los Angeles

Gary YoungBoston University

*NASI member

iv N a t i o n a l A c a d e m y o f S o c i a l I n s u r a n c e

Acknowledgements

The National Academy of Social Insurance and its study panel on Medicare and Markets grate-fully acknowledge the assistance of a number of individuals for their help on this report. Wereceived assistance from several staff members at the Centers for Medicare and MedicaidServices, including Nancy Delew, Michael McMullan, Edward Sekscenski, and Robert Streimer.In particular, we are grateful to Carlos Zarabozo for his tireless participation throughout thepanel process, including providing the panel with data and for his careful review of several draftsof the report. The study panel also benefited from presentations by Curtis Florence, MarshaGold, Marian Gornick, Beth Stevens, and Ken Thorpe. We are also thankful to Henry Aaron,Chairman of NASI and Robert Reischauer, Chair, NASI Medicare Steering Committee for theiradvice and counsel throughout the project. We would like to express our appreciation to DavidColby, our project officer at the Robert Wood Johnson Foundation for his support during theproject. Finally, we would like to express our appreciation to Jill Bernstein and Beth Docteur,former members of the NASI staff, and to Reginald Williams, health policy research assistant atNASI for his contributions to the research and careful preparation of the report. Any errorsremain those of the authors.

1T h e R o l e o f P r i v a t e H e a l t h P l a n s i n M e d i c a r e

The National Academy of Social Insurance(NASI) convened a study panel in 2001 toconsider the role of market-oriented reformsand private health plans in Medicare, as partof its broader project on the future of theMedicare program. The panel interpreted itscharge broadly and set as its goal strengthen-ing Medicare overall, including both the fee-for-service (FFS) system and private healthplans. Members of the study panel wereselected for their recognized expertise andknowledge of Medicare; they were alsoselected to represent different disciplines anddiverse views on the role of private healthplans in Medicare. The study panel met fourtimes, convened several conference calls, andcommissioned original research in pursuit ofits mission. In its work, the panel strove toreach consensus on a wide range of challeng-ing and complex issues. In most cases, thepanel reached a common understanding andviewpoint, however, on some issues, therewas a divergence of views among panel mem-bers, which is noted in the text. This is thepanel’s final report.

Proponents of increasing the role of marketforces and private health plans in Medicareargue that original Medicare’s fee-for-servicepayment system is antiquated and inherentlyincapable of meeting the challenges of mod-ern health care delivery, serving poorly bothbeneficiaries and taxpayers.1 They maintainthat it creates incentives for unnecessary(sometimes harmful) and uncoordinatedmedical care, leaves beneficiaries exposed tosubstantial financial risk, inefficiently allocates

resources, thwarts innovation through out-dated benefits and rigid payment systems,lacks accountability, and invites excessiveCongressional involvement in the program’smanagement and operations. They furthersuggest that Medicare ought to provide ben-eficiaries with the same array of private healthplans through which many working-ageAmericans get health insurance.

Opponents of market-based reform inMedicare, while agreeing that benefit cover-age and financial protections for beneficiariesmust be greatly improved, argue that marketforces will undermine a very popular socialinsurance program that has effectivelyimproved the health care and financial statusof elderly and disabled Americans. In theirview, competition among private healthplans, variations in their individual practices,and plan movement in and out of theMedicare market inevitably undermine bene-ficiaries’ financial security, create inequity inbenefits, promote unevenness in coverage,and disrupt relationships with physicians. Intheir view, shifting benefits and administrativerequirements can overwhelm those with cog-nitive or sensory impairments. They maintainthat competition among private health planscreates incentives for plans to avoid the sickand market to the healthy, increasing the vul-nerability of frail Medicare beneficiaries. Theyassert that cost control through competitionis more myth than reality.

In the study panel’s view, debate over theappropriate role of market forces in Medicare

Executive Summary

1 In this report, the terms “original Medicare,” “FFS Medicare,” and “FFS” are used interchangeably.

often has been characterized by misunder-standing and polarized by ideology, withclaims that do not comport with experience.They do not expect that a better understand-ing of Medicare’s history and analysis of itsperformance alone will result in a consensusview on Medicare reform. Values play animportant part — and rightly so — in shap-ing views about public policy. But they hopethat a dispassionate analysis of both originalMedicare and Medicare+Choice (M+C)2

will help clarify the issues and dispel somemisconceptions.

As the complexity of Medicare has grown,misunderstanding has increased. As newgoals have emerged for the program, policiesintended to advance some goals have inad-vertently undermined others. As Medicare’sadministration has grown more complex, ithas become harder to make sense of whateach part of the program is intended toachieve. For example, while some view theM+C program as the “market” part ofMedicare, its payments to plans are estab-lished in law, rather than by market forces,and while it has offered some choice for themajority of beneficiaries, effective competi-tion among private health plans has occurredonly in certain portions of the country.

Participants in the debate often rely on ideal-ized conceptions of their favored part of theprogram. Some proponents of increasedinvolvement by private health plans havebased their predictions on conceptions of howmarkets could work if they were used for alarge percentage of Medicare beneficiaries,not on their actual experience in Medicare or

how well these plans have performed forworking age Americans. Some opponentshave evoked an old-fashioned version of fee-for-service medicine, one in which beneficia-ries choose freely among doctors andhospitals of equal quality, all willing to treatthem, and appropriate care is unconstrainedby imperfect rules or bureaucratic red tape.

Neither of these views speaks to the currentand future reality of the Medicare program: avital asset for beneficiaries as individuals andas a group, but one that suffers from seriousshortcomings, inefficiencies, and inequities.Neither offers a realistic assessment of thecapacity for market-oriented reforms toimprove Medicare’s performance, comparedto a system with only original Medicare.

Given this range of views, the study paneldecided that the best way to begin its work was through an objective analysis ofMedicare’s current performance, both in FFSand M+C, along a number of crucial dimen-sions. The panel evaluated Medicare’s perfor-mance in providing financial security, choiceof plans and providers, access to health care,quality of care, cost containment, and reduc-ing the prevalence of racial, ethnic, socio-economic, and gender disparities in the provision of health care. By using multiplecriteria, the study panel sought an in-depthunderstanding of the program’s performance.Providing a clearer picture of Medicare’s successes and limitations also focuses policy-makers’ attention on larger challenges facingMedicare, regardless of the way services aredelivered.

2 N a t i o n a l A c a d e m y o f S o c i a l I n s u r a n c e

2 The Medicare+Choice program refers to the range of private health plans authorized by Congress in theBalanced Budget Act of 1997.

The panel found a number of shortcomings inMedicare, with some more pronounced inoriginal Medicare and others in M+C. Neitheroriginal Medicare nor M+C is ideally struc-tured, or has performed optimally, to remedythe following weaknesses in the program:

■ Medicare was enacted with the promiseto provide financial security and accessto medical care comparable to that ofinsured working-age Americans. It nolonger does so. While Medicare pro-vides very good access to care for elder-ly beneficiaries, those with moderateincomes or chronic illnesses are at riskfor health care expenses that far exceedtheir ability to pay for it.3 For disabledbeneficiaries, Medicare provides access tocare equivalent to employer-sponsoredinsurance.4 But the financial burden ofpaying for care falls harder on disabledbeneficiaries, 39 percent of whomreported that they were unable to paytheir medical bills. Another 33 percentsaid they had to alter their lifestyles topay for health care (Davis et al. 2002).

■ Original Medicare has not kept pacewith the benefit packages of the vastmajority of employer-sponsored healthinsurance plans, which typically coverprescription drugs (although with grow-ing restrictions), preventive services, and

an annual cap on out-of-pocket liability(Kaiser Family Foundation and HealthResearch and Educational Trust 2002).5

■ The fee-for-service reimbursement sys-tems in original Medicare do not pro-mote effective chronic care because theypay providers only for discrete servicesrendered, not to manage the care ofpeople with complex health care needs.This approach fragments care, instead ofencouraging a team approach or coordi-nation among providers (Eichner andBlumenthal 2003).

■ Medicare will face increasing fiscal con-straints in the years ahead, as the babyboom generation becomes eligible forbenefits. Medicare currently accountsfor 2.6 percent of the Gross DomesticProduct (GDP), and is projected toincrease to 4.75 percent by 2030. Bythen, the aging of the baby boom gen-eration will cause the number ofMedicare beneficiaries to almost doubleto 79 million. (Board of Trustees2003).6

■ Medicare has locked in historical anddramatic geographic differences in theresources used for the care of beneficia-ries, with per capita expenditures insome parts of the country two to threetimes higher than spending in other


3 For example, beneficiaries with annual incomes less than $10,000 spent almost 30 percent of their income onhealth care. Twenty percent of elderly beneficiaries have incomes in this range (CMS 2002b).

4 Disabled beneficiaries experience more access barriers than elderly beneficiaries.

5 Original Medicare covers none of these benefits, while Medicare beneficiaries enrolled in some M+C plans,most notably in high payment areas, have received some of these additional benefits.

6 Although the study panel is mindful of these issues, its mission did not include examining Medicare financing forthe future. A companion NASI report, Financing Medicare’s Future (September 2000), focuses on that issue.

N a t i o n a l A c a d e m y o f S o c i a l I n s u r a n c e

7 Most of these differences persist after costs are adjusted to account for differences in the costs of the inputmeasures (Wennberg, Fisher, and Skinner 2002).

8 Medicare is not unique in this respect; disparities are pervasive throughout the U. S. health care system.

regions.7 The M+C program has insti-tutionalized these inequities, whichencourages participation and richer ben-efits in plans located in high-paymentareas.

■ Quality of care for Medicare beneficia-ries appears to fall short of that forworking-age adults with health insur-ance, in large part because its beneficia-ries are in frailer health and are morelikely to have multiple chronic condi-tions. As a result, Medicare beneficiariesseem more likely to suffer from medicalerrors with serious adverse outcomes.They also tend to be more likely toexperience greater difficulties in coordi-nation of health care services.

■ Although Medicare provides all benefi-ciaries with the same health insurancecoverage, there are still dramatic dispari-ties in the use of health care servicesrelated to race and ethnicity as well associo-economic status.8

To rejuvenate Medicare’s commitment tobeneficiaries and the American public, its per-formance should be improved. To fulfill itscharge, the Panel sought to identify the waysin which market-oriented reforms mighteither facilitate or impede these improve-ments. This assessment required that we (a) disentangle multiple concepts that areoften commingled under the rubric of “mar-ket reforms,” (b) determine how the distinc-tive needs and circumstances of Medicarebeneficiaries should alter the design andscope of market-oriented reforms, (c) identify

those shortcomings in Medicare’s currentperformance that are not easily cured by mar-ket reforms, and (d) propose arrangementsthat could increase accountability in bothoriginal Medicare and the private health plansthat contract with the program. Not all ofthe program’s shortcomings are solvable byany feasible policy, but many could be moreeffectively addressed than they are today, orin any currently proposed reforms.

SORTING OUT THE CHANGESINVOLVED IN MARKET ORIENTEDREFORMS

Advocates of market reforms in Medicarepromise benefits linked to two distinctchanges in Medicare. The first involves givingbeneficiaries choices of private health plans asan alternative to original Medicare. The sec-ond seeks to create competition amonghealth insurance options based on both priceand quality. Although both are oftengrouped together as “market reforms,” ourfindings suggest that (a) they have very dif-ferent implications for Medicare beneficiaries,(b) some of these changes are more readilyimplemented than others, (c) we know moreabout the implications of some of thesechanges than others, and (d) confusion abouttypes of market-oriented policies has cloudedthe debate over Medicare reform.

Since its inception, Medicare has contractedwith private health plans to provide servicesto beneficiaries who choose them. Beginningin 1997, private health plan options havebeen called the “Medicare+Choice”

4

program.9 Following enactment of theBalanced Budget Act and changes in themanaged care industry, the types and num-bers of plans and the stability of their partici-pation in Medicare markedly changed.

Insufficient information about the role of pri-vate health plans in Medicare makes it diffi-cult to have a comprehensive understandingof their effects. A fair amount of evidenceabout the relative performance of some typesof M+C plans, particularly risk-based HMOsexists, but less information is available aboutthe performance of Preferred ProviderOrganizations (PPOs), Provider-SponsoredOrganizations (PSOs), and private FFS(PFFS) plans. There is evidence that theimpact of private health plans tends to bemore beneficial, the more competitive is thelocal market.10 But we know very little aboutthe potential for competition based on priceand quality. Medicare’s payments to privatehealth plans are based on prices set by law,rather than those generated by market forces.Efforts to create competition based on quali-ty are still in their infancy. For insights intothe potential costs and benefits of these typesof plans and full price competition, we mustlook to the experience of employer-basedinsurance.

Drawing upon these sources of evidence andexperience, the study panel finds that theinvolvement of private health plans inMedicare is promising, in that:

■ Medicare beneficiaries and the generalpublic both favor providing greaterchoice of health plans, as long as thisdoes not undermine the affordability oforiginal Medicare.

■ Giving beneficiaries a choice of plans,with differing benefits, helps policy-makers and plans identify which planfeatures or benefits are important tobeneficiaries. In general, Medicare bene-ficiaries value choice of plans, thoughonly a subset (typically younger or dis-abled beneficiaries) makes a seriouseffort to consider choice. But choiceunder M+C has been seriously restrictedbecause plans are not equally availablethroughout the country and becausepractices by Medigap insurers limit ben-eficiaries’ ability to switch freelybetween M+C plans and originalMedicare.

■ Access to coordinated care plans hasallowed some beneficiaries to reducesignificantly the burden of paperworkand improve their financial security. Inaddition, coordinated care plans haveimproved diagnosis of illness andreduced disparities related to race andincome for preventive services.Although PFFS plans have been operat-ing for too short a time to have anestablished track record, early indica-tions suggest that they are not produc-ing the same gains as coordinated care


9 The Balanced Budget Act of 1997 defined several types of private health plans that could contract withMedicare. Coordinated care plans include risk-based HMOs, Provider-Sponsored Organizations (PSOs) andPreferred Provider Organizations (PPOs). Private Fee for Service (PFFS) plans are not included in the definitionof coordinated care plans.When the term “coordinated care plan” is used in this report, the BBA definition isused.

10 (Pizer and Frakt 2002), for example, found that M+C plans offered more generous coverage when they oper-ated in more competitive markets.

plans with respect to enhanced financialsecurity.

■ Enrollment in coordinated care planshas the potential to produce a one-timereduction in Medicare spending on theorder of 5 to 7 percent.11 However, todate, Medicare has not realized savingsbecause M+C plans have enrolled dis-proportionate numbers of relativelyhealthy enrollees who would have costless in original Medicare. Savings arenot achieved because payments to plansare not adequately risk-adjusted toaccount for enrollees’ better health sta-tus. Instead, these savings have gonelargely to beneficiaries in the form ofadditional benefits that are not part ofthe Medicare benefit package. Althoughthere are ongoing efforts to improverisk adjustment, it is unclear whetherthese alone will be sufficient to achieveMedicare cost savings for the foresee-able future.

■ Price-based competition has the poten-tial to further reduce program spendingand (depending on the format of thecompetition) reduce geographic dispari-ties in Medicare spending. BecauseMedicare has no experience in thisarena, potential benefits are uncertain.The Centers for Medicare and MedicaidServices (CMS) actuaries have estimatedsavings at 2 to 3 percent of programspending over 30 years; others have esti-mated larger savings, achieved by shift-ing costs to beneficiaries.

THE DISTINCTIVE CHALLENGES OFMARKET-ORIENTED REFORM FORMEDICARE

Defining an appropriate role of private healthplans for the elderly and disabled does not, inthe panel’s assessment, require that theMedicare program be remade in the image ofthe private market for employer-based healthinsurance. Indeed, emulation of all aspects ofemployer-based insurance would be counter-productive, because Medicare beneficiarieshave needs, circumstances, and capacities that differ in important ways from those ofworking-age adults.

To serve beneficiaries well, Medicare mustreflect these differences. In the assessment ofthis panel, two differences standout as essen-tial guideposts for policy-making:

First, nearly 13 percent of Medicare benefi-ciaries have both cognitive and physicalimpairments. These impairments rise withage, with more than 25 percent of beneficia-ries over age 80 having both cognitive andphysical impairments (Moon and Storeygard2001). About two-thirds of beneficiaries havemultiple chronic conditions. Twenty percentof aged beneficiaries and 14 percent of dis-abled beneficiaries have five or more chronicconditions (Eichner and Blumenthal 2003).A third of all beneficiaries have vision that isno better than fair, another 17 percent havelimited literacy (Gold et al. 2001). For thesegroups, the opportunities for choice that areappealing (or at least manageable) to youngerbeneficiaries might seem threatening, or


11 These estimates reflect the net savings associated with lower spending on medical care in M+C plans, com-bined with their higher costs for marketing, administration, and profits.

simply be beyond their capabilities. The samedynamic qualities of markets that make themso appealing to policy-makers because of flex-ibility and innovation can be problematic forbeneficiaries who need stability and reliability,especially in their relationships with healthcare providers. These are not simply prefer-ences; they become a necessary part of lifefor those trying to cope with multiple healthproblems, or whose mental capacity may bediminished.

A second distinctive feature of the programinvolves the health needs of beneficiaries:many live with chronic illnesses. Sixty-six per-cent of aged beneficiaries and 62 percent ofdisabled beneficiaries had more than onechronic condition (Eichner and Blumenthal2003). The experience of working-aged peo-ple with chronic illnesses suggests that theydo not benefit much from plan choice.Because they are reluctant to disrupt conti-nuity of care with their health care providers,they often remain in plans that are perform-ing poorly, even when given a number ofalternative plans from which to select. Pastexperience with some M+C plans andemployer-based plans also suggests that forpeople with chronic health problems, thebenefits of coordinated care plans might beoffset by the perceived problems in access tospecialists and disruptions in continuity ofcare. These shortcomings are exacerbatedwhen plans leave the program.

To this end, the panel believes that Medicarebeneficiaries should have an option to remainin FFS Medicare. Most panel membersbelieve that original Medicare should remaina vital program and serve as a safety net, in

the event that private health plans fail orwithdraw from Medicare, or for beneficiarieswho want greater stability than M+C planshave provided. The panel recognizes theshortcomings of FFS in meeting the complexneeds of beneficiaries who are disabled orhave multiple chronic conditions. In theirview, maintaining and improving originalMedicare is critical precisely because it servesa disproportionate number of vulnerablebeneficiaries, including the oldest beneficia-ries and those who are disabled.12

While the study panel agreed that beneficia-ries should have an option to remain in origi-nal Medicare, they differ don how originalMedicare should be treated in a more mar-ket-based system. The treatment of originalMedicare in a competitive environment wasthe most difficult issue the panel considered.This is not surprising because it is also one ofthe most contentious issues in the 2003Congressional debate on prescription drugsand Medicare reform.

The panel agreed that assured access tohealth insurance has been an importantaccomplishment of the Medicare program,and one that should be preserved in someway. However, members of the panel differedover how that would be best accomplished.

Most panel members believe that FFSMedicare is essential to an assurance of uni-versal access to coverage, so much so thatFFS Medicare should not to be placed indirect price competition with private healthplans because that could jeopardize the via-bility of FFS Medicare in the market.Experience in the Federal Employees Health


12 See a companion NASI report, Medicare in the 21st Century: Building a Better Chronic Care System (Eichner andBlumenthal 2003) for recommendations to improvements in the care of beneficiaries with chronic illnesses.

N a t i o n a l A c a d e m y o f S o c i a l I n s u r a n c e8

Benefit Program (FEHBP) has shown thatcompetition can lead to a “death spiral” asrelatively healthier enrollees flee high costplans for lower cost plans, ultimately increas-ing costs in the high cost plans. They fearthat if FFS Medicare were placed in directprice competition with private health plans;FFS premiums might increase to the pointthat FFS could become unaffordable forlower income beneficiaries.

A few panel members disagreed with thisview. They believe that original Medicare canand should compete directly with privatehealth plans, with one modification. BecauseMedicare payments include not just healthcare provided to Medicare beneficiaries, butalso costs associated with larger social goals,such as graduate medical education and pay-ments for hospitals serving disproportionatenumbers of low income people, payments forthese functions should be paid separately —“carved out” — from payments made forproviding services to Medicare beneficiaries.This would assure continuing funding forthese services.

These panel members believe that protectionof FFS Medicare from price competition withprivate health plans is logically and practicallyinconsistent with the desire to make choicesavailable to beneficiaries, and to use compar-isons among options to monitor performanceand improve the accountability of FFSMedicare. They recognize, however, thatdirect price competition could be disruptiveto vulnerable beneficiaries, particularly thosewith cognitive impairments or serious illness-es. They propose to create insurance that

would protect vulnerable beneficiaries fromincreases in premiums above a pre-deter-mined amount. But most panelists viewedsuch insurance as inadequate, offering nosafeguard for vulnerable beneficiaries againstthe unexpected cuts in coverage, discontinu-ities of care, disrupted relationships with doc-tors, and rising out-of-pocket costs that haveresulted from unstable participation by pri-vate plans in the M+C program.

The study panel also considered the adequacyof Medicare benefits. The program’s lack ofprescription drug coverage and an annual capon out-of-pocket health care spending hasput the program out of step with prevailingpractices in large employer-based insuranceand exposed beneficiaries to unacceptablefinancial risk. Therefore, the panel recom-mends that these benefits be added to bothoriginal Medicare and M+C. The panel ismindful that these reforms will increase thecost of the program.13 Coupled with theconcern about keeping FFS premiums afford-able, these proposals made some panelistsfear that original Medicare would simplybecome too expensive to be politically sus-tained over the long term. But the majorityof the panel concluded that political andmanagerial accountability for cost contain-ment is strong, noting that the costs of origi-nal Medicare had grown more slowly thanthe costs of employer-based insurance overthe past two decades.14

Finally, the Study Panel concluded that thecontinued vitality of Medicare depends onreforms in the market for supplemental insur-ance (Medigap) policies. These policies pro-

13 Caps on out-of-pocket spending can be budget-neutral if there are offsetting increases in the deductibles orpremiums paid by Medicare beneficiaries (Maxwell, Storeygard, and Moon 2002).

14 This difference remains even when one takes into account changes in coverage in both private insurance andMedicare over this period of time.

vide an important source of additional cover-age for those who desire greater financialsecurity. But current pricing practices makethese policies unaffordable to most of thosewho qualify for Medicare coverage due todisability. And they can trap elderly beneficia-ries in M+C plans that provide inadequatecare, because their Medigap premiums wouldbe higher because of impaired health status ifthey switched back to original Medicare.15

The panel therefore endorsed federal reformsto require community-rated Medigap cover-age with open enrollment. Some panelistsexpressed concern that these reforms couldlead to the sickest enrollees concentrating insome Medigap plans, driving premiums up inthose plans to a point that they were nolonger affordable. To limit adverse selection,consideration should be given to restrictingthe number of times beneficiaries are allowedto switch between FFS Medicare and M+Cplans, and to limiting the number ofMedigap options offered with community-rating.

THE LIMITATIONS OF MARKETREFORMS: PROBLEMS THAT REQUIREPROGRAM-WIDE STRATEGIES

The potential benefits of greater choice ofprivate health plans and greater competitionamong plans are significant. For some benefi-ciaries, particularly the relatively young andhealthy, these benefits may be highly valued.Market-oriented arrangements should berefined to make these benefits more widely

available to Medicare beneficiaries. We offersome specific recommendations to this end.But it is equally important to be clear aboutwhat market-oriented reforms, even in theirmost refined form, will not bring toMedicare.

■ There is little evidence that market-based reforms have slowed the rate ofgrowth in private health spending in thelong term, compared to the historicaltrend.

■ Involvement of private health plans inMedicare has limited potential forenhancing financial security for benefi-ciaries who are most likely to incur highout-of-pocket costs. The advantages ofthe average coordinated care plan inM+C in reducing out-of-pocket costsfor beneficiaries who are disabled orwho have chronic illnesses have erodedas co-payments and coverage limitationshave become more common, althoughsome plans have had more positiveexperiences.

■ It is essential to recognize that marketsare, by their nature, dynamic. Thisresults in substantial changes over timein benefits covered by M+C plans,turnover among physicians affiliatedwith each plan, as well as continuingentry and exit of plans from theMedicare program. Minority and dis-abled beneficiaries and those in frailhealth are disproportionately affected bythis instability.16 Although constrained


15 Some options currently exist. A half-dozen states require that Medigap premiums be community-rated (set atthe average actuarial cost for both healthy and unhealthy enrollees); AARP offers a community-rated policy toits members. But the majority of the panel felt that a reliance on state intervention or a private group likeAARP offered neither reliability nor equity in the treatment of Medicare beneficiaries. (See Chapter three formore details.)

16 The most recent assessment of the impact of M+C plans leaving the Medicare program was provided byBooske, Lynch, and Riley (2002).

M+C payment rates have exacerbatedthe instability, much of the instabilityappears to be due to industry-widepractices outside the control of theMedicare program.

■ Without adequate risk adjustment, pri-vate health plans have weak incentivesto improve quality for beneficiaries withexpensive chronic conditions (thoughsome do offer disease management pro-grams), which are more prevalentamong older people and those who aredisabled. Under current Medicarefinancing mechanisms, private healthplans have few incentives to reduceeither racial or socio-economic dispari-ties in medical care and they may, undersome circumstances, exacerbate thosedisparities.17 Private health plans havereduced disparities in terms of preven-tive care, although substantial disparitiesrelated to race and income remain. Anddisparities are not reduced for treatmentchoices and the quality of follow-upcare.

Problems related to financial insecurity,growing costs, quality shortfalls, and unequaltreatment will thus persist in Medicare,whether benefits are administered throughoriginal Medicare or private health plans.Therefore, changes must be made to addressthese concerns, applied with equal vigor toboth parts of the program.

We identify below some of the most pressingof these program-wide reforms, though we

defer to other reports many of the detailedrecommendations for their structure orimplementation. But we believe that thesesorts of specific reforms will be effective onlyif more fundamental changes are made toensure that the Medicare program is adminis-tered in an effective and accountable manner.

ENHANCING MEDICARE’SACCOUNTABILITY

To address these concerns, the study panelbelieves that both original Medicare andMedicare’s private health plans need to bemore accountable, which will require a trans-formation of Medicare’s governing culture.For too long, Medicare replicated the prac-tices of a 1960s version of private insurance,focusing on paying claims and promotingaccess, to the detriment of other goals. CMShas focused on broader administrative goalsin recent years, although the participation ofdifferent types of private health plans since1997 adds to the challenges of effectiveaccountability. But the superficial differencesbetween the two parts of the program shouldnot obscure the fact that both have histori-cally relied on the same three mechanisms toencourage accountability:

■ Consumer Accountability: emphasizesindividual beneficiaries assessing theirown experiences and responding whenthey think that better outcomes can befound with other providers or in othersettings.


17 It should be noted that private health plans have historically enrolled a disproportionate number of low-incomebeneficiaries, although the most recent data on minority enrollment shows little difference between FFS andM+C plans. (Thorpe and Atherly 2002).

■ Political Accountability: involves theoversight provided by Congressionalcommittees charged with the supervi-sion of the program.

■ Managerial Accountability: is exer-cised by CMS, the federal agency thatadministers the program; insurers andother organizations under contract toCMS; the Secretary of the U.S.Department of Health and HumanServices (HHS); and various other gov-ernment agencies, such as the GeneralAccounting Office (GAO) and theOffice of the Inspector General inHHS.

Although original Medicare is often seen asaccountable primarily to the political process,both consumer choice and CMS monitoringof performance have played important rolesin improving the program’s performance.And although market-based reforms areoften justified in terms of consumer account-ability, both Congress and CMS have had anactive role (for better and worse) in govern-ing the M+C program.

Each of these approaches to accountabilityhas demonstrated distinct strengths andweaknesses, which are reflected in the trackrecord comparing Medicare FFS and M+Cover the past 15 years (Figure 1). Consumeraccountability has the strength of relying onindividual choices, which reflect the diverseneeds and preferences of Medicare beneficia-ries. But consumers, even if well informed,cannot readily judge some aspects of qualityor have much sense of disparities in treat-ment. CMS has assumed leadership inencouraging quality improvement, but isconstrained by both political considerationsand resource limitations in its ability to inter-act creatively with providers, beneficiaries, or

health plans. Political oversight has a crucialrole to play in striking the right balanceamong Medicare’s various goals and deter-mining the appropriate level of expendituresfor the program.

It is precisely because the different parts ofthe Medicare program embody differentarrangements for accountability that eachpart of the program can serve as an impor-tant standard of comparison for assessing andimproving the performance of the other part.And because these different combinations ofaccountability arrangements produce a dis-tinctive pattern of strengths and weakness, itis the combination of both public and privateforms of Medicare that offers the greatestaccountability. The differences between origi-nal Medicare and M+C ought to be viewedas assets for the program, not problems thatought to be eliminated by future reforms.

The study panel thus considers it essentialthat both original Medicare and its privatehealth plan contractors be encouraged tolearn from each other’s experience. In thisway, new innovations or important lessonsfrom one part of the program will encourageimprovements in the other. The perceivedstability that makes FFS Medicare attractiveto more frail beneficiaries could becomeundesirable stasis, if not stimulated by innov-ative practices in private health plans.Conversely, the experimentation of privatehealth plans could degenerate into disorder,without having original Medicare as a stan-dard for comparison and a focus for politicalsupport. Original Medicare and M+C canand should be seen as useful complements toone another.

To ensure that each part of the programlearns from the other, mechanisms foraccountability need to be strengthened to



Figure 1

Summary Comparisons of Performance of Original Medicare and M+C

FinancialSecurity

Choice

Access

Quality

CostContainment

Racial, Ethnicand Income-relatedDisparities

Inadequate, particularly for poorbeneficiaries and beneficiaries whoare older and in frailer health.

Maximum choice of health careproviders. Restricted choice amongMediap plans for the disabled andelderly beneficiaries who wish tochange plans several years afterretirement.

Better than employer-based insur-ance, but emerging access problemsin some geographic areas. Access fordisabled not as good as for elderly.

Achievements: Industry leader inaccess to cutting edge medical tech-nologies; quality improvement initia-tives on par with most progressive in employer-based insurance.Shortfalls: Treatment at “wrong”sites; excessive use of therapies;inadequate primary and preventivecare and follow-up; medical errors;failures of coordination.

From 1970-1998, Medicare performed slightly better than the private sector.

Systematic and sustained differencebetween whites and blacks, andbetween low and high-income beneficiaries, including; primary and preventive care, use of surgicaland follow up. Limited evidence ondisparities in care for Latinos andAsians. Gender disparities limited;largely related to age and income.

Better than FFS, but eroding in past five years.More responsive to changing technologies, asillustrated by coverage of prescription drugs. Butmore risky for beneficiaries whose plans leave theprogram or who disenroll voluntarily.

Plans concentrated in densely populated areasand not available in many parts of the country.Few areas have multiple choices. Less choice ofproviders than in FFS.

For those enrolled, access to providers does notappear to be a problem. Access disrupted for beneficiaries when plans leave program. Accessfor disabled not as good as for elderly.

Similar quality problems as FFS, except: a higherpercentage of beneficiaries have an establishedrelationship with a primary care provider; higherimmunization ratio; some cancers identified earlier.But continuity of care and communication tend tobe worse than in FFS settings. Care seems to beless effective for older enrollees with more severeand chronic health conditions.

Introduction of coordinated care plans could produce one-time savings of 5-7 percent, but only if risk adjustment improved and implemented.Annual growth rates thereafter are similar to original Medicare.

Only one study that compare disparities betweenFFS & M+C shows higher black immunizationrates. Other studies suggest a reduction in dispari-ties for primary and preventive care, but with nocomparable reductions in disparities for follow-upcare. Similar to FFS for disparities between lowand high income. No evidence on other racial,ethnic, or gender disparities.

Fee-For-Service M+C

reinforce connections between originalMedicare and M+C. To promote consumeraccountability, beneficiaries should be effec-tively informed about the comparative per-formances of original Medicare and M+Cplans. They should understand that the twoforms of insurance are indeed one program, arecognition that may be threatened by cur-rent M+C practices (See chapter five). Topromote managerial accountability, CMSshould act as a managerial “bridge” betweenthe two parts of the program, facilitating thetransfer of lessons and incorporating incen-tives for improved performance. CMS willneed new resources to pursue a more activerole in assuring access and quality of care,following the trend of many of America’slarge employers in recent years. And it arguesagainst dividing program administration intoseparate parts for original Medicare andM+C, as proposed in some Medicare reformplans. To promote more effective politicalaccountability, Congress needs to becomemore involved in setting goals and prioritiesfor both original Medicare and M+C and inensuring that that both parts of the programpursue these goals with equal vigor, withoutmicromanaging program operations.

If accountability in Medicare is enhanced inthis manner, we believe that originalMedicare and M+C can operate in effectivesynergy. This would allow more effectiveresponses to the findings that we reportbelow, and more effective implementation ofthe specific reforms that follow from thefindings.

FINDINGS AND RECOMMENDATIONSOF THE STUDY PANEL

The History of Private health plans inMedicare (Chapter Two)

Finding: Early decisions about how to struc-ture the participation of private health plansin Medicare have had lasting and problematicramifications; repeated Congressional effortsto ameliorate unforeseen effects have some-times done more harm than good, and havedamaged the government’s reputation as areliable business partner.

Finding: Over time, Congress has increasedpolicy objectives for private health plans tothe extent that not all objectives can be metbecause some objectives are contradictory.

Finding: Effective competition among M+Cplans is strongest in urban areas. Havingmultiple plans, each with distinctive providerpanels, is unlikely to be feasible in rural areasbecause of the difficulty of building and sus-taining viable networks in sparsely populatedareas.

Finding: Private fee-for-service (PFFS) plansare currently providing beneficiaries withsome additional benefits not covered byMedicare, but fewer than those provided bycoordinated care plans. However, becausePFFS plans operate primarily in low costareas that receive “floor” payments, Medicarepayments to PFFS plans are well in excess ofthe costs that original Medicare would incurfor Medicare-covered services.

Finding: Even with unstable participation,caused in part by constrained Medicare pay-ment rates, the participation of private health


plans in Medicare has brought certain bene-fits to the program as a whole.

Finding: The way M+C plans are currentlypaid does not rely on market forces. The pay-ment structure Congress established in law isan administered pricing system, not a market-based system.

Finding: The entrance and exit of privatehealth plans in Medicare, whatever the cause,results inevitably in disruptions in access tocare and continuity of care, as well as changesin coverage of extra benefits.

The Financial Security of MedicareBeneficiaries (Chapter Three)

Finding: Original Medicare does not provideadequate financial security to beneficiaries,particularly those with limited incomes andchronic health problems. Many low-incomebeneficiaries eligible for additional federalassistance are not enrolled in the means-tested programs intended to help them payfor health care because they are not informedabout these programs, or are reluctant toapply for them.

Finding: Private health plans have providedgreater financial security to some beneficiariesthan original Medicare. However, greaterfinancial security is associated only withenrollment in some coordinated care plans,not PFFS plans. For beneficiaries in frailhealth, ongoing reductions in coverage incoordinated care plans are exposing them tosubstantially greater financial risk than in pre-vious years.

Recommendation: The Medicare programshould incorporate an annual limit on out-of-pocket spending for Medicare covered services.

Recommendation: The Medicare programshould provide Medicare beneficiaries withaccess to outpatient prescription drug cover-age to protect them against large out-of-pocket expenses.

Choices Available to Beneficiaries(Chapter Three)

Finding: Some Medicare beneficiaries arewilling and able to choose and switch amongcompeting health plans. However, it is notrealistic to expect all beneficiaries to do so,especially those with multiple chronic condi-tions or cognitive impairments. For thosebeneficiaries, policies that require annualreconsideration of their insurance options, orswitching health plans can be very disruptiveto continuity of care or a source of confusion.

Finding: Failures in the market for Medicaresupplemental policies are preventing someMedicare beneficiaries from trying M+Cplans, and locking other beneficiaries invol-untarily into M+C plans. Medigap premiumsthat are adjusted for health status or deniedentirely to beneficiaries who are disabled trapless healthy beneficiaries, who are unable todisenroll without having to either foregosupplemental coverage or pay much higherpremiums. Beneficiaries with moderateincomes are most likely to become trapped inthis manner.

Recommendation: Beneficiaries must beassured that original Medicare is available inall areas and will remain so over time. Mostpanel members believe that keeping originalMedicare premiums affordable should be apriority, but that view was not unanimous.


Recommendation: Medicare supplementalpolicies should be community-rated, withgreater freedom to switch among plans. Toprevent adverse selection, considerationshould be given to restrictions on the num-ber of times beneficiaries can switch betweenFFS Medicare and M+C plans, or on thenumber of plans that are available on a community-rated basis.

Access to Care (Chapter Three)

Finding: Both original Medicare and M+Chave provided good access to care so far,with original Medicare performing betterthan employer-based insurance for aged ben-eficiaries. However, access to care is betterfor aged beneficiaries than disabled beneficia-ries, regardless of whether they are enrolledin original Medicare or M+C.

Cost Containment and Market Forces(Chapter Three)

Finding: Private health plans have the as-yetunrealized potential to achieve modest one-time cost savings for the Medicare program,on the order of 5 to 7 percent for coordinat-ed care plans and 2 to 3 percent for premiumsupport programs. However, under currentprice-setting practices, these savings depend,respectively, on more effective risk-adjust-ment and national premium-setting thathave, to date, proven technically difficult andpolitically infeasible. The savings associatedwith coordinated care plans may not apply toprivate fee-for-service plans because of thehigher payment rates they receive in “floorcounties.”

Finding: There is little evidence that privateinsurance, which relies on market forces, hasreduced the rate of growth in private healthspending over the long term, compared toeither the historical trend or the rate ofincrease in Medicare spending.

Recommendation: Medicare should conductcompetitive pricing demonstrations to payprivate health plans. Most panel membersthink that original Medicare should beexcluded from the demonstration to protectit against adverse risk selection, although afew panel members think it should be included. These demonstrations should testboth competitive bidding and the FederalEmployees Health Benefits Program(FEHBP) models.

Quality of Care (Chapter Four)

Finding: Despite aggressive new policies byCMS to improve quality, low quality remainsan important problem for Medicare. Moststrikingly, none of the current mechanismsfor monitoring quality under either originalMedicare or M+C can measure certain cru-cial dimensions of practice, such as errors intreatment, selection of appropriate venues for treatment, or adequate coordination ofcare for beneficiaries with multiple chronicconditions.

Recommendation: The performance moni-toring systems (CAHPS, HEDIS) used byCMS to measure access to care under origi-nal Medicare and M+C should include newmeasures related to chronic illness, as well asincreased sample sizes of disabled enrollees.

Recommendation: CMS should modify theMedicare conditions of participation for hos-pitals to require mandatory reporting of


adverse events that result in death or seriousharm. CMS should also develop the capacityto identify beneficiaries admitted to low-volume hospitals for procedures where outcomes are sensitive to the volume of procedures performed. CMS should beencouraged to consider a system that couldprospectively screen such admissions.

Recommendation: CMS should develop andimplement a payment system for health plansthat incorporates explicit incentives forimproving quality of care. Parallel incentivesshould be established for FFS providers. Inthe short-run, these may be limited to physi-cians in group practice in FFS Medicare, buteventually should be extended to all physicians.

Recommendation: Congress should giveCMS the necessary resources and authorityto stimulate changes to improve quality ofcare for beneficiaries, such as expandedrequirements for geriatric training for clini-cians treating Medicare beneficiaries, andcapacity to promote regionalization of carefor procedures shown to have a relationshipbetween volume and quality.

Finding on Disparities in Care Based onRace, Ethnicity, Socio-economic Status,and Gender (Chapter Four)

Finding: Racial, ethnic, and income-relateddisparities exist in preventive care, primarycare, and essential medical and surgical treat-ments. These are of a magnitude that meritsimmediate redress.

Finding: Racial, ethnic, and income-relateddisparities in preventive care are reduced bybeneficiaries’ enrollment in coordinated careplans. Evidence is mixed in terms of the qual-ity of primary care, and there is no evidence

that coordinated care plans reduce racial orincome-related disparities in essential medicaland surgical treatments.

Recommendation: CMS should measureand assess disparities in preventive care, pri-mary care, essential medical and surgical pro-cedures, and follow-up treatment on aregular basis. Disparities based on race, eth-nicity, socio-economic status, and gendershould be studied in both original Medicareand M+C. Aggregate measures should bereported on an annual basis. Plan-specificmeasures should be used whenever possibleto encourage improvement at the local level.

Findings on Collateral Missions ofMedicare (Chapter Five)

Finding: Support for the current Medicareprogram is lower in communities where thereis substantial Medicare enrollment in privatehealth plans. In areas where private enroll-ment exceeds 30 percent of all Medicare beneficiaries, support for taxes to financeMedicare’s future is at half the level found inother communities. Lower levels of supportfor government involvement are most pro-nounced in promoting quality and equity oftreatment among beneficiaries.

Recommendation: CMS should help benefi-ciaries better understand that they areenrolled in Medicare regardless of whetherthey receive care through original Medicareor an M+C plan, and the conditions underwhich they can disenroll from M+C andreturn to original Medicare. This educationaleffort must be carefully designed to clarify thestructure of the program, while not confusingbeneficiaries about the terms under whichthey have enrolled in particular M+C plans.


Findings on Accountability (Chapter Six)

Finding: Medicare lacks sufficient consumer,political, and managerial accountability inboth original Medicare and M+C to assureoptimal performance.

Recommendation: Mechanisms should bedeveloped to ensure greater consumer, politi-cal, and managerial accountability that moreeffectively stimulates learning between origi-nal Medicare and M+C. This would require(a) providing all beneficiaries with compara-tive information on performance of the twoparts of the programs, regardless of whetherthey are actively considering a switch

between the two, (b) providing CMS withadditional resources, and allowing it to retainmanagerial responsibility for both parts of theprogram, and (c) encouraging Congress tomore effectively and consistently monitor theperformance of both FFS Medicare andM+C plans with respect to broad programgoals and priorities, without micromanagingthe program’s operations.

Recommendation: Congress should create amore stable environment for the M+C pro-gram by refraining from legislating frequentchanges in the program’s structure and pay-ment rates.


The Board of Trustees, Federal Hospital Insurance and Federal Supplementary MedicalInsurance Trust Funds. 2003. Annual Report of the Board of Trustees of the Federal Hospital andFederal Supplementary Medical Insurance Trust Funds, 2003. Washington, DC.

Booske, Bridget, Judith Lynch, Gerald Riley. 2002. “Impact of Managed Care MarketWithdrawal on Beneficiaries.” Health Care Financing Review 24(1): 95–115.

Centers for Medicare and Medicaid Services (CMS). 2002b. Medicare Program Informationfrom the Medicare Current Beneficiary Survey. Baltimore: Centers for Medicare and MedicaidServices.

Davis, Karen, Cathy Schoen, Michelle Doty, and Katie Tenney. 2002. “Medicare versus PrivateInsurance: Rhetoric and Reality.” Health Affairs web exclusive posted October 9, 2002.

Eichner, June, and David Blumenthal, eds. 2003. Medicare in the 21st Century: Building aBetter Chronic Care System. Washington, DC: National Academy of Social Insurance.

Gold, Marsha, Michael Sinclair, Mia Cahill, Natalie Justh, and Jessica Mittler. 2001. MonitoringMedicare+Choice: Medicare Beneficiaries and Health Plan Choice. Washington, DC: MathematicaPolicy Research, Inc.

Kaiser Family Foundation, and Health Research and Educational Trust. 2002. Employer HealthBenefits: 2002 Annual Survey. Menlo Park, CA and Chicago: Kaiser Family Foundation andHealth Research and Educational Trust.

Maxwell, Stephanie, Matthew Storeygard, and Marilyn Moon. 2002. Modernizing MedicareCost-Sharing: Policy Options and Impacts on Beneficiary and Program Expenditures. New York:The Commonwealth Fund.

Moon, Marilyn, and Matthew Storeygard. 2001. One-Third at Risk: The Special Circumstancesof Medicare Beneficiaries with Health Problems. New York: The Commonwealth Fund.

Pizer, Steve and Austin Frakt. 2002. “Payment Policy and Competition in the Medicare+ChoiceProgram.” Health Care Financing Review 24(1): 83–94.

Thorpe, Kenneth, and Adam Atherly. 2002. “Medicare+Choice: Current Role and Near TermProspects.” Health Affairs web exclusive posted July 17, 2002.

Wennberg, John, Elliott Fisher, and Jonathan Skinner. 2002. “Geography and the Debate overMedicare Reform.” Health Affairs web exclusive posted February 13, 2002.


References

The National Academy of Social Insurance (NASI) is a nonprofit, nonpartisan organi-zation made up of the nation’s leading experts on social insurance. Its mission is topromote understanding and informed policymaking on social insurance and related

programs through research, public education, training, and the open exchange of ideas.Social insurance encompasses broad-based systems for insuring workers and their familiesagainst economic insecurity caused by loss of income from work and the cost of health care.NASI’s scope covers social insurance such as Social Security, Medicare, workers’ compensa-tion, unemployment insurance, and related public assistance and private employee benefits.

The Academy convenes steering committees and study panels that are charged with conduct-ing research, issuing findings and, in some cases, reaching recommendations based on theiranalyses. Members of these groups are selected for their recognized expertise and with dueconsideration for the balance of disciplines and perspectives appropriate to the project.

The views expressed in this report do not represent an official position of the NationalAcademy of Social Insurance, which does not take positions on policy issues, or its funders.The report, in accordance with procedures of the Academy, has been reviewed by a commit-tee of the Board for completeness, accuracy, clarity, and objectivity.

The Academy wishes to thank the Robert Wood Johnson Foundation for its generous support of this project.

© 2003 National Academy of Social InsuranceISBN# 1-884902-40-5

Suggested Citation:

King, Kathleen M. and Mark Schlesinger, (eds.), Final Report of the Study Panel on Medicareand Markets—The Role of Private Health Plans in Medicare: Lessons from the Past, Looking tothe Future (Washington, D.C: National Academy of Social Insurance, September 2003).

NATIONAL ACADEMY OF SOCIAL INSURANCE1776 Massachusetts Avenue, NW 202/452-8097

Suite 615 Fax: 202/452-8111

Washington, DC 20036 www.nasi.org




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