Who is enrolled in for-profit vs. nonprofit Medicare HMOs?

We compare the characteristics of enrollees in for-profit and nonprofit Medicare health plans using nationwide data from the 1996 Medicare Current Beneficiary Survey. We find few differences in overall health status, limitations in activities of daily living (ADLs), or history of chronic disease. However, older Americans enrolled in for-profit plans are substantially poorer and less educated than those enrolled in nonprofit plans, are more likely to have joined their plan recently, and are more likely to have joined a plan with the expectation of reducing their out-of-pocket health care costs.     

Are Medicare HMOs the promise of the future?

Companies are looking at using HMOs to reduce their retiree medical costs. But first there are obstacles to overcome.     

Why do so few HMOs offer Medicare risk plans in rural areas?

Only 17 of the 38 health maintenance organizations (HMOs) that have Medicare risk contracts and offer coverage to commercial clients in rural counties include the rural counties in their Medicare plan service areas. Rural counties in which HMOs offer Medicare coverage have higher average adjusted average per capita costs (AAPCCs), larger populations, and more physicians per capita than rural counties excluded by risk plans. Interviewed plans cite low and erratic AAPCCs, scarcity of potential enrollees, lack of negotiating power with physicians, and adverse selection as drawbacks in rural areas. Proposed changes to the payment methodology would probably lead HMOs to increase their Medicare offerings in urban fringe areas, but not in isolated rural areas.     

What does voluntary disenrollment from Medicare+Choice plans mean to beneficiaries?

The Balanced Budget Act (BBA) of 1997 required CMS to report publicly Medicare managed care (MMC) plan voluntary disenrollment rates. To ensure disenrollment rates would be meaningful to beneficiaries in health plan choice, CMS funded the development of surveys and reporting formats to identify and present the reasons that beneficiaries voluntarily leave plans. Public reporting of reasons on the Medicare Web site began in 2002. We discuss results from extensive audience testing of disenrollment rates and reasons materials. Medicare beneficiaries do not easily understand disenrollment. We also discuss challenges in presenting useful disenrollment information and policy implications for public reporting.     

Who really wants price competition in Medicare managed care?

There is much policy talk about making Medicare more competitive, like private markets. But when reform proposals near implementation, local opponents of competition are often able to stop reform experiments. This paper reports on one recent example, the Competitive Pricing Advisory Committee, created by the 1997 Balanced Budget Act (BBA) to bring competitive bidding to Medicare + Choice plans. After design and site-selection choices were announced, members representing local interests were able to delay and perhaps kill competitive bidding before it could start, once again. A public report of this story may save future market-based Medicare reforms from a similar fate.     

Do Medicare HMOs still reduce health services use after controlling for selection bias?

This study models the relationship between Medicare beneficiary decisions to join Medicare HMOs and subsequent health services utilization. The relationship between health plan choice and utilization is thought to be endogenous because of favorable selection into HMOs. Previous studies found significantly lower inpatient utilization among Medicare HMO enrollees than among nonenrollees, but lacked strong controls for selection bias. Thus, a firm conclusion could not be drawn as to whether the observed differences were attributable to the HMO practice setting or to baseline differences in the illness profiles of the two groups studied. The present study uses simultaneous equations methods, including discrete factor estimation, to test the effect of Medicare HMOs on utilization when strong controls for selection bias are imposed. The model was run on a panel of 1993-1996 data from the Medicare Current Beneficiary Survey, supplemented with linked data on Medicare HMO characteristics and area supply characteristics. The study found that even when favorable selection is controlled for, Medicare HMOs significantly reduce both the probability of hospitalization and the number of inpatient days used by those who are hospitalized. Medicare HMOs do not, however, appear to reduce the use of physician services.     

Who needs to know?

Health plans need to collect data on mental health services to ensure quality and improve care. But can they do this and protect patient confidentiality at the same time?     

Who really profits from not-for-profits?

In a Harvard Business Review (1987) article, Herzlinger and Krasker suggested that not-for-profit hospitals do not return more benefit to society than do for-profit hospitals, and the authors questioned the legitimacy of social subsidization of not-for-profits. Our article reports findings from an empirical reconsideration of the question, "Who profits from nonprofits?" We used hospital data from the same time period (1982) as that used by Herzlinger and Krasker; however, our investigation analyzed a larger data set (including both system and nonsystem hospitals) and used a different statistical technique (discriminant analysis). Our findings suggest that not-for-profits return more social benefit (e.g., in the areas of services provided, access to care, and involvement in professional education) than do for-profits. Like Herzlinger and Krasker, we find that for-profit hospitals may be more efficient than not-for-profits. We caution that public policy regarding social subsidization of not-for-profit hospitals should be made only after more intensive study and thoughtful consideration.     

Who has time to sleep?

BACKGROUND: Both marriage and education appear to confer a protective effect on health. Few studies have examined the extent to which both undersleeping and oversleeping explain these relationships. I examined whether marital status, educational background, and other sociodemographic variables are associated with higher-risk sleep durations. METHODS: Over 7000 individuals aged 25-64 collected time-use diary data during a 24-h period. For both weekdays and weekend days, separate multinomial logistic regression models were estimated using three categories of sleep duration as the outcome category. RESULTS: Unmarried individuals are significantly more likely to sleep a short amount on both weekdays and weekends compared to married people. Single people also are significantly more likely to sleep a long amount. People with less than a college education are significantly more likely to sleep both a short amount and a long amount on weekdays relative to the college educated. CONCLUSIONS: High-risk sleep durations (short sleeping and long sleeping) are positively associated with sociodemographic categories associated with poorer health. More research should investigate whether social inequalities in health can be explained in part by variation in sleep duration.