Managed Care - January 2009 - (Page 8)

NEWS AND COMMENTARY Favorable Reg Provisions Increase MA Enrollment ver the past several years, changes in laws and regulations have encouraged greater plan participation and enrollment growth in the Medicare Advantage (MA) private fee-for-service (PFFS) market, according to “The Emerging Role of Group Medicare Private Fee-for-Service Plans” from the Henry J. Kaiser Family Foundation. Legislation such as the Medicare+ Choice program, created by the 1997 Balanced Budget Act, expanded private plan options for employers and individuals to include PPOs, PFFS plans, and medical savings accounts. In 2003, the Medicare Modernization Act authorized MA, which replaced the M+C. Other regulatory waivers issued by the Centers for Medicare and Medicaid Services made PFFS plans more attractive to employers, unions, and plan sponsors by reducing administrative and operational barriers. And in 2009, group HMOs and PPOs can extend coverage to retirees living in areas where the plans don’t have provider networks. They can function like non-network PFFS plans, which do not restrict enrollee choice among providers who agree to accept the plan’s payment terms, are licensed, and have a Medicare billing number. The report details the emerging role of group Medicare PFFS plans: • Enrollment in group PFFS plans has expanded from almost 33,000 in 2006 to over 600,000 in 2008. It constitutes 36 percent of the total MA enrollment. • In 2006, nine health plan organizations offered group PFFS plans. In 2008, there were 41. Aetna and Blue Cross Blue Shield of Michigan have the most enrollees in group PFFS plans, together capturing over half of the market. O Headlines On Deadline Purchasers are increasingly requiring health plans to focus on the quality of health care delivered to consumers, according to the National Business Coalition, which says that more health plans are reducing barriers to essential treatments. For example, 27 percent of plans are waiving copayments for diabetes drugs and 33 percent have reduced copayments Low Medicare and Medicaid payments to hospitals and physicians lead to significantly higher insurance costs for consumers and employers, according to a study by Milliman. The study found that annual health care spending for an average family of four is $1,788 higher than it would be if Medicare, Medicaid, and private insurers paid hospitals and physicians at similar rates. Government payers tend to underpay hospitals and physicians. This creates a payment gap that privately insured employers and consumers must close through cost shifting, which is the difference between actual payment rates and average payment rates Nineteen percent of employees are willing to pay higher premiums in order to keep deductibles and copayments lower and more predictable, says a survey from Watson Wyatt. Last year, though, 38 percent chose the higher premiums. Some workers are taking actions that could lead to higher costs in the future. For example, 17 percent reported that they avoided a recommended doctor’s visit this year to save costs. Similarly, 17 percent did not fill a prescription or skipped doses of prescribed medications, an increase from 13 percent in 2007. — Tony Berberabe Few Americans Use In-Store Clinics Although retail clinics seem to be popping up everywhere, only a small fraction of American families have ever used them, according to a study conducted by the Center for Studying Health System Change. The number of retail clinics has grown rapidly in recent years, from about 60 in 18 states at the beginning of 2006 to more than 900 in 30 states by the end of 2007. But as of 2007, only 2.3 percent of American families (nearly 3.4 million families) had ever used one. Families that reported not getting or delaying needed medical care were almost 2.5 times as likely to have used a retail clinic as families without such access difficulties (1.9 percent vs. 0.8 percent). Also, young families — those with a family member age 18– 34, were more than twice as likely as older families — those with a family member age 50–64 to have used a retail clinic. Highlights from the report include: • Families with at least one member lacking health insurance accounted for 27 percent of clinic users, according to the study. • Nearly half of all clinic users cited the low cost of a clinic visit. • Uninsured users were more than 3.5 times as likely as insured users to cite the lack of a usual source of care as a major reason for choosing retail clinics. 8 MANAGED CARE / JANUARY 2009

Table of Contents Feed for the Digital Edition of Managed Care - January 2009

Managed Care - January 2009 Editor's Memo Contents Legislation & Regulation News and Commentary Medication Management Compensation Monitor Health Care's Disruptive Innovations Q&A With Clayton Christensen 'Disruption' May Be Plans' Best Bet Avoid the PBM Rebate Trap HealthPartners Puts Diabetes on Notice Formulary Files Plan Watch Tomorrow's Medicine Ad Index Outlook Unmet Needs in the Management of Plaque Psoriasis Impact of RSV: Implications for Managed Care

Managed Care - January 2009

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