Department  of Health  and  Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
BENEFICIARY  PERSPECTIVES  OF

MEDICARE  RISK  HMOS

Summary  Report 
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 MARCH  1995 
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+ OEI  06-91-00736 
%j~o Beneficiary  Perspectives  of  Medicare  Risk  HMOS 
Summary  Report 
PURPOSE 
This  report  describes  beneficiaries  perspectives  of the  Medicare  risk  HMO  experience. 
For  a more  detailed  discussion,  S=  the  companion  technical  report  entitled  Beneficiary 
Perspectives  of Medicare  Risk  HMOS,  OEI  06-91-00730. 
BACKGROUND  AND  METHODOLOGY 
lMedicare  beneficiaries  may join  a risk  health  maintenance  organization  (HMO)  through 
the Medicare  program.  Under  a risk  contract,  Medicare  pays  the HMO  a predetermined 
monthly  amount  (capitated  rate)  per  enrolled  beneficiary.  In return,  excepting  hospice 
care,  the HMO  must  provide  all Medicare  covered  services  that  are  medically  necessary. 
Once  enrolled,  beneficiaries  are  usually  required  to use HMO  physicians  and  hospitals 
(lock-in)  and  to obtain  prior  approval  from  their  primary  care  physicians  for  other  than 
primary  care. 
As of July  1,  1994,  HCFA  reported  136 risk-based  HMO  plans  served  2,036,279 
Medicare  enroilees.  1  The  Office  of Managed  Care  within  the  Health  Care  Financing 
Administration  (HCFA)  has  oversight  responsibility  for Medicare  risk  contmcts  with 
HMos. 
Using  HCFA  databases,  we selected  a stratifkd,  random  sample  of 4,132  enrollees  and 
disenrollees  from  45 Medicare  risk  HMOS.  Since  our  primary  focus  is Medicare 
beneficiaries  perceptions  of their  risk  HMO  experience,  we collected  information  directly 
from  beneficiaries.  We  did  not  attempt  to validate  their  :esponses  through  record  review 
or HMO  contact.  (See  Appendix  A for  details  of methodology.) 
This  inspection  was  conducted  in accordance  with  the  Quahy  Standards for  Inspections 
issued  by the Presidents  Council  on Integrity  and  Efficiency. 
FININNGS 
Generally,  beneficiary  responses  indictie  Medicare  risk  lZWOs  provided  axiequale  service 
access for  most  benejiciunes  who  had joined. 
The  majority  of enrollees  and  disenrollees  reported  medical  care  that  maintained  or 
improved  their  health,  timely  appointments  for  primary  and  specialty  care,  good  access  to 
Medicare  covered  services  and  to  hospital,  specialty  and  emergency  care,  and  sympathetic 
personal  treatment  by  their  HMOS  and  HMO  doctors.  In  some  instances,  however, 
enrollees  and disenrollees  differed  markedly  in reporting  their  HMO  experiences.  When 
this  happened,  we  describe  the  difference  as a point  of comparison.  Overall,  HMO  beneficiaries  seemed  relatively  healthy.  Howe ver,  disenrollees  repoited  a 
much  gretier  decline  in health  stalus  dunng their  HMO  stay  and  were  much  more  likely 
to biame their  HMO  care for  their  declining  health. 
Enrollees  and disenrollees  self-reported  similar  health  problems,  but  rated  their  health 
status  differently.  Two-thirds  of both  groups  reported  no  serious  health  problems;2  the 
majority  of both  rate  their  health  as good  to exceLlent.  However,  ciisenrollees  tended  to 
rate  themselves  in poorer  health  overall  than  the enrollees  had  comparable  health 
Whi) 
problems.  Both  groups  also  self-reported  deteriomting  health  ovfir time,  but  at 
disenrolhnent,  19%  fewer  disenrollees  rated  their  health  as  good  to excellent  compared  to 
when  they  fwst joined  their  HMOS.  This  is more  than  double  the  9% rate  of decLine from 
good  to excellent  health  reported  by  enrollees  when  we  surveyed  them.  HCFA  data 
showed  65%  of disenrollees  and  77%  of enrollees,  who  answered  our  survey,  were 
enrolled  in the  sampled  HMOS  more  than  12 months. 3 
Another  important  difference  between  enrollees  and  disenrollees  was  how  they  rated  the 
effectiveness  of the  HMO  care.  Disenrollees  (22%) were  ten times  more  likely  than 
enrollees  (2% ) to believe  the  medical  care  received  through  the  HMO  caused  their  health 
to worsen.  Fully  half  of enrollees  said  HMO  care  improved  their  health  compared  to only 
one-third  of disenrollees. 
Benejiciury  responses  indicate  HMOS generally  adhered  to  Federal  standurds  for 
enrollment  procedures,  but  screening  for  health  status  at applic~on  and  a lizck of 
beneficiary  awareness  of appeal  rights  were  apparent  problem  arem. 
Beneficiaries  recollections  and perceptions  indicate  that  HMOS  generally  informed 
beneficiaries  about  application  procedures,  lock-in  and prior  approval  for  specialty  care. 
However,  their  responses  also  indicate  weaknesses  in enrollment  procedures  and  in 
beneficiary  understanding  of individual  appeal/grievance  rights.  With  the  exceptions  of 
ESRD  and  the  election  of hospice  care,  Federal  regulations  prohibit  HMOS  from  denying 
or discouraging  enrollment  based  on  a beneficiarys  health  status.  HMOS  must  also 
adequately  inform  beneficiaries  about  lock-in  to the  HMO  and  grievance/appeal 
procedures.  Forty-three  percent  of beneficiaries,  who  could  remember,  said  they  were 
asked  at application  about  their  health  problems,  excluding  kidney  failure  and  hospice 
care.  Between  2 % and  3 % reported  a physical  examination  was  required  before  they 
could join  the  HMO,  an event  that  should  never  occur. 4  We  specifically  asked 
beneficiaries  about  their  experiences  at application.  However,  some  HMOS  conduct  a 
health  assessment  interview  shortly  after  enrollment.  If some  of these  responses  refer  to 
such health  assessments,  this  may  have  inflated  our  data.  Also  problematic  is the  fact  that 
25%  didnt  know  they  have  the  right  to appeal  the  HIIOS  refusal  to provide  or pay  for 
services. 
2
 Most  beneficiaries  repotied  timely  doctor  appointments  for  primary  and  specialty  care, 
but  some  enrollees  and  disenrollees  experienced  noteworthy  debys;  busy  telephone  lines 
caused  appointment  difficulties  for  some  beneficianes. 
Timely  appointments  includes  days  elapsed  before  a scheduled  appointment,  time  spent 
waiting  in an office  to  see a doctor  and  the  ease  (or  difficulty)  of the process  for 
scheduling  appointments. 
b  Appointments:  The  great  majority  of beneficiaries  reported  they  got  appointments 
within  1 to 2 days  when  they  believed  they  were  very  sick,  but  enrollees  (94%)  were 
more  likely  than  disenrollees  (85%)  to get  quick  appointments.  Fully  78%  of 
beneficiaries  usually  waited  8 days  or less  for  appointments  with  primary  doctors  and  63% 
usually  waited  the  same  for  appointments  with  specialists.  A substantial  group  (16%  to 
26%)  of enrollees  and  disenrollees  said  they  typically  waited  from  13 to more  than  20 
days  for  scheduled  appointments  for primary  and  specialty  care.  Moreover,  the  waiting 
times  for  scheduled  appointments  differed  little  between  the  self-reported  healthier  and 
sicker  beneficiaries. 
b  Office  waiting  time:  Disenrollees  (20 ?O) were  almost  3 times  as likely  as 
enrollees  (7% ) to report  waiting  1 hour  or  more  in the  office  to  see their  primary  HMO 
doctors. 
b  Telephone  access:  Busy  telephone  lines  hindered  some  beneficiaries  access  to 
services  by affecting  their  ability  to make  appointments  for  care.  Disenrollees  (34%) 
encountered  consistently  busy  telephone  lines  almost  twice  as often  as enrollees  (19%)  and 
11%  of all beneficiaries  said they  sometimes  gave  up trying  to make  appointments. 
The greal  majority  of benejiciaties  believed  they  received  the  Medicare  services  they 
needed  and  were personally  well-treated;  however,  disenrollees  were  more  likely  to 
perceive  problems  with  access  to pnmary  and  speciu.lty  care,  to  seek  out-of-plan  care 
and  to report  their  HMOS  or pnmary  docto~  unsympdtetic  behanors. 
A large  majority  of enrollees  and  disenrollees  believed  their  primary  HMO  doctors  and 
HMOS  provided  the  necessary  care.  They  consistently  reported  good  access  to Medicare 
covered  services  and  to hospital,  specialty  and  emergency  care. 
b  Access  to primary  and  specialty  care:  Disenrolkxx  reported  more  access 
problems  in three  categories.  First,  disenrollees  said  their  primary  HMO  doctors  failed  to 
provide  Medicare  covered  services  nearly  5 times  as often  as enrollees.  Second, 
disenrollees  were  much  more  likely  than  enrollees  to report  their  doctors  failure  to  give 
the necessary  referrals  to specialists.  In  fact,  disenrollees  with  self-reported  serious 
illnesses  were  more  than  twice  as likely  to  report  this  denial  of referrals  than  disenrollees 
with  none.  Third,  disenrollees  more  often  reported  HMOS  refusals  to pay  for  emergency 
care  compared  to enrollees.  5 
3
 Only  4%  of all beneficiaries  reported  being  told  by medical  or  office  staffs  that  a needed 
medical  ser,ice  was  not  covered  by the HMO.  The  most  frequently  mentioned  services 
were  chiropractors  (37 %),  laboratory  tests  and  x-rays  (14 %),  and  medical  equipment  for 
home  use  (11 %) -- all  of which  are  Medicare  covered  services  with  some  restrictions. 
Although  based  on  a few  responses,  this  may  indicate  a problem  with  HMO  service 
provision  and/or  beneficiary  understanding  of available  services. 
Out-of-plan  care:  Excluding  dental,  routine  eye,  and  emergent/urgent  care,  7% 
k 
of all beneficiaries  had  sought  out-of-plan  care  for Medicare  covered  services  without 
prior  approval  from  their  primary  HMO  doctors  or the HMO.  Disenrollees  (22%)  went 
out-of-pkm  3 times  as often  as enrollees  (7%).  Reasons  most  often  given  for  seeking  out
of-pkm  care  were  perceived  access  problems,  such  as needing  the  unapproved  care,  not 
getting  services  quickly  enough,  and  not being  helped  by the  primary  HMO  doctor. 
Another  reason,  not  knowing  they  would  have  to pay  for  out-of-plan  care,  illustrates 
beneficiary  misunderstanding  of lock-in. 
k  Unsympathetic  behavior  by  doctors  or HMOS:  Unsympathetic  behavior  of 
primary HMO  doctors,  their staffs and HMO  office  staff can directly  or subtly  restrict 
beneficimies  access  to medical  services.  We  found  only  slight  evidence  (less  than  1%)  of 
beneficiaries  being  told  their  medical  needs  could  not  be accommodated.  Overall,  about 
11%  of beneficiaries  perceived  more  subtle  kinds  of personal  treatment  problems  that  can 
indirectly  restrict  access. 6  Disenrollees  (39%)  were  more  than  3 times  as likely  as 
enrollees  (12 %) to  believe  their  primary  HMO  doctors  did  not  take  their  health  complaints 
seriously.  However,  over one-third  of these  disemollees  and  enrollees  said  they 
encountered  this  attitude  most  to all  of the  time.  Disenrollees  were  also  more  likely  than 
enrollees  to believe  that  holding  down  the  cost  of care  was  more  important  to their 
primary  HMO  doctors  (28 % vs.  10%)  or their  HMOS  (35 % vs.  11%)  than  giving  the best 
medical  care possible. 
Disabled/ESRD  disenrollees  most  often  repotied  access  problems  in several  cwcti  areas 
of their  HMO  care;  many  disa.bled/ESRD  enrollees  wanted  to  leave. 
Disenrollees  who  are disabled  or who  have  ESRD  are  a small  (an estimated  2,300 
beneficiaries),  highly  critical  group. 7  They  were  twice  as likely  as aged  disenrollees  and 
41 times  as likely  as disabled/ESRD  enrollees  to say  that  medical  care  received  through 
the  HMO  caused  their  health  to worsen.  In  addition,  they  were  the  most  likely  to report 
that  their  primary  HMO  doctors  restricted  access  to  needed  Medicare  covered  services, 
didnt  refer  them  to  specialists  when  necessary,  and  didnt  take  their  health  complaints 
seriously.  They  were  also  the  most  likely  to  seek  out-of-plan  care  while  still  enroUed  in 
the  HMO  and to believe  that  holding  down  the  cost  of care  was  more  important  to 
primary  HMO  doctors  and  the  HMOS  than  providing  the  best  medical  care  possible.  We 
also  found  discontent  among  disabled/ESRD  enrollees  with  66%  saying  they  wanted  to 
leave  their  HMOS. 
4
 Almost  one-~hird  of disenrollees  Iejl  solely for  administr~ve  reasons;  the  remaznder 
voiced  more  cnticism of their  HMO  expenence;  16?70of enrollees  etiher  planned  to  leave 
their  HMOS,  m  wanted  to leave  but feh  they  could  not. 
Responses  from  the  29%  of disenrollees  who  left their  HMOS  for  administrative  reasons 
tended  to dilute  the  criticism  of other  disenrollees.  Administrative  reasons  refer  to 
business  or procedural  actions  rather  than  to beneficiary  choice.  Non-administrative 
disenrollees  were  substantially  more  negative  than  administrative  disenrollees  regarding 
their  experience  with  appeal  rights,  effectiveness  of HMO  care,  waiting  time  for 
appointments,  and  personal  treatment  receivd  from  the primary  HMO  doctor  and  the 
HMO. 
Eighty-four  percent  of enrollees  had  no plans  to leave  their  HMOS,  but  the  remaining 
16%,  an estimated  150,000  beneficiaries,  either  planned  to leave  or wanted  to leave  but 
felt  they  could  not.  Two  percent  planned  to move  out  of the  HMOs  service  area,  4% 
planned  to leave  for  non-administrative  reasons,  and  the final  10 % wanted  to  leave  but  felt 
they  could  not,  primarily  because  of the  relative  affordability  of HMO  care. 
The leading  disenrollment  reasons  based  on personal  preferences  were  discomfort  with 
the  restricted  care  choices  and  high  beneficiary  expenses,  while  top  reasons  related  to 
service  access  are  difficulties  with  hmely appointments  and  with  obtaining  needed 
primary  and  specialty  care. 
Beneficiaries  personal  preferences  in a health  care  delivery  system  and  their  perceptions 
of  access  to services  through  the HMOS  constituted  two  non-administrative  categories  of 
reasons  for  leaving  or  wanting  to leave  the  HMOS.  Within  the personal  preference 
category,  enrollees  and  disenroIl&s  most  frequently  cited  discomfort  with  the  HMO 
restrictions  on providers  and  services,  plus  high  beneficiary  premiums/co-payments,  as 
reasons  for leaving.  Perceived  access  problems  showed  some  differences  between 
disenrollees  and  enrollees  as well  as  some  similarities.  A telling  distinction  was  19%  of 
disenrollees  reported  they  left because  of getting  sicker  as a result  of the  care  received 
through  the HMO,  compared  to only  4%  of enrollees.  Disenrollees  were  1.5  to 2 times 
as likely  as enrollees  to choose  the  reasons  of long  office  waits  and  lack  of fast  service 
when  they  believed  they  very  sick.  However,  four  reasons  were  listed  among  the  top  five 
by both  groups: 
b  waiting  too  long  for  scheduled  appointments,

F  not  being  allowed  to  see  the  necessary  specialists,

F  wsiting  too  long  at the  office  to see the  doctor,  and

b  being  unable  to get  services  fast  enough  when  they  were  very  sick.

5
 Choice  ojprimary  HMO  doctors  and  high  benejicimy  expenses  were  the  two  most 
important  reasons  for  leaving  or  wanting  to  leave  the  HMC%. 3 
Five  rezsons  for  leaving  an HMO  were  the  most  frequently  given  and  were  among  those 
rated  most  important  by both  disenrollees  and  enrollees.  Both  groups  said  they: 
didnt  like  the choice  of primary  HMO  providers:

b 
b  believed  their  premiums  and/or  co-payments  were  too  expensive;

b  wanted  to  use the  doctors  they  had  before  they joined  the HMO;

b  were  not  alIowed  to see the  specialists  they  believed  they  needed  to  see;  and

h  were  refused,  by their  primary  HMO  cioc~ors, services  they  believed  they

needed. 
The  choice  of primary  HMO  doctors  and  high  beneficiary  expenses  were  the  two  most 
important  overall  disenrollment  reasons  for  both  groups.  Both  groups  perceived  problems 
with  service  access,  but  disenrollees  seemed  to feel  a greater  impact  on their  health  as a 
result,  i.e.,  they  were  getting  sicker.  Enrollees  reasons  for  planning/wanting  to  leave 
were  predominantly  personal  preferences  for  health  care  delivery. 
RECOMMENDATIONS 
As the health  care  reform  debate  continues  and  a means  to control  health  care  costs  is 
sought,  the HMO  form  of managed  care  has  received  increased  attention.  To  provide 
further  information  for  the  ongoing  debate  and  to assist  HCFA  in its management  of 
Medicare  risk  HMOS,  we present  these  recommendations  based  on our  survey  results. 
As discussed,  beneficiary  responses  indicate  Medicare  risk  HMOS  provide  adequate 
service  access  for  most  beneficiaries  who  have joined.  However,  our  survey  results  also 
indicate  some  serious  problems  with  enrollment  procedures  and  service  access  that  we 
believe  require  HCFAS  attention.  Our  intent  here,  and  in subsequent  reports  based  on 
the same  survey  data,  is not to prescribe  specitlc  corrective  actions.  Instead,  we  want  to 
identify  for HCFA,  based  on information  from  beneficiaries,  areas  Of the  Medicare  risk 
HMO  program  apparently  needing  improvement  and to  suggest  techniques  HCFA  can  use 
to further  monitor  these  areas. 
Three  items  need  immediate  exploration: 
	 Beneficiaries  should  be better  informed  about  their  appeal  rights  as required 
by Federal  standards.  Fully  25%  of beneficiaries  did  not know  they  could  appeal 
their  HMOS  refusals  to provide  or pay  for  services.  We  believe  knowledge  of 
appeal  rights  is an extremely  important  issue  when  viewed  in combination  with 
lock-in  to the  HMOS  and  the  fact  that  12%  of all HMO  beneficiaries  perceived 
their  primary  HMO  doctors  did  not  take  their  health  complaints  seriously. 
6
 +	 Service  access  problems  reported  by  disabled/ESRD  beneficiaries  need  to be 
carefully  examined,  as they  are  an  especially  vulnerable  group.  Moreover,  the 
problems  cited  in their  survey  responses  parallel  February,  1994  Congressional 
testimony  regarding  HMO  care  of the  disabled.9 
k  Medicare  risk  HMOS  should  be  monitored  for  inappropriate  screening  of 
beneficiaries  health  status  at application.  More  than  2 of 5 beneficiaries,  who

could  remember,  said the y were  asked  at application  about  their  health  problems.

A recently  pubLished  study 10 of Medicare  risk  HMOS  found  that  these  plans

attract  healthier-than-average  beneficiaries.  While  the  study  concludes  this

appears  to  be due primarily  to self-selection  of enrollees,  since  HMOS  must  enroll

an interested  Medicare  beneficiary,   our  data  suggest  the possibility  of  health

screening  and  selective  enrollment  by HIM(3s, as an alternate  explanation.

Several  other  beneficiary-reported  issues  of access  to services  through  HMOS  merit 
examination  by HCFA  in the  near  future  for  possible  cause  and  resolution.  The  access 
issues  concern: 
b	 Routine  Appointments  -- Some  beneficiaries  reported  having  difficulty  making 
appointments  for  services  in terms  of the days  waited  for  scheduled  appointments, 
apparently  without  regard  to their  health  status.  Others  said  they  sometimes  gave 
up trying  to  make  appointments  because  of consistently  busy  telephone  lines. 
b	 Health  Maintenance  -- Some  beneficiaries  reported  being  unable  to  see  their 
primary  HMO  doctors  within  1 or 2 days  when  they  felt they  were  very  sick. 
Some  also  believed  their  HMO  medical  care  caused  their  health  to worsen. 
F	 Refusal  of  Services  -- Some  beneficiaries  reported they  were  refused  referrals  to 
specialists,  payments  to a doctor  or  hospital  for  emergency  care,  or Medicare 
covered  services  because  the  HMO  purportedly  did  not  cover  them. 
Based  on our  experience  with  this  survey,  we  suggest  consideration  of three  items  as 
HCFA  conducts  field  tests  of its  survey  instrument  for  disenrolling  HMO  beneficiaries, 
F  Allow  disenrollees  to communicate  as many  reasons  for  leaving  the  HMC) as 
are applicable  to their  situation.  Confiig  a beneficiary  to only  one  reason  may 
mask  underlying  problems  of  which  HCFA  needs  to be aware. 
F	 Distinguish  bet ween  adrninistrative  and  non-administrative  disenrollments. 
Because  of the  major  differences  between  administrative  and  non-administrative 
disenrollees,  it appears  advisable  to treat  them  separately  when  monitoring 
managed  care  settings.  Also,  if disenroll.ment  rates  are  to be a performance 
indicator,  HCFA  may  want  to exclude  administrative  disenrollments  or  treat  them 
sepamtely. 
7
 b	 Conduct  these  exit  surveys  by  mail  with  computer  itinerated  forms,  either 
exclusively  or  in conjunction  with  other  methods  In this way,  as the  GHP  or 
other  data  base  is updated  with  disenrolhnent  information,  HCFA  could  routinely 
and  systematically  collect  information  from  all or a portion  of disenrollees. 
Additional  Office  of Inspector  General  Work 
Other  Inspector  General  reports,  either  in progress  or planned,  are  also  intended  to assist

HCFA  in its examination  and  management  of HMO  issues.  From  this survey  data  we

plan  to complete  an HMO  level  report  showing  the  distribution,  frequency  and

characteristics  of HMOS  relative  to the  enrollment  and  access  issues  reported  by

beneficiaries.  We  also  plan  to produce  a report  that  explores  tke value  and  use  of

disenrolhnent  rates  as an HMO  performance  indicator  and  that  analyzes  the  most

sigfilcant  reasons  for  beneficiary  disenrollments.  Other  subjects  of future  HMO  reports

are  a determination  of  how physicians  and  beneficiaries  view  their  relationship  in an HMO

setting  and  how  well  Medicare  beneficiaries  enrolled  in HMOS  understand  their  appeal

rights  and  have  them  protected.

AGENCY  CONliWEiiTS 
HCFA  concurred  with  the  reports  recommendations.  The  agency  reports  it is focusing 
on improved  ways  to communicate  with  beneficiaries,  and  spectilcally  the Medicare  HMO 
enrollee.  The  report  findings  and  recommendations  may  also  be part  of its efforts  to 
support  action  in certain  areas  of beneficiary  access  and  education.  Finally,  HCFA  will 
utilize  the  report  as part  of its data  collection  and  information  gathering  efforts  to assess 
beneficiary  access  to  managed  care  services  and  the  extent  of beneficiary  knowledge  on 
how to use  these  services. 
The  Assistant  Secretary  for  Planning  and  Evaluation  suggested  the  inclusion  of other 
research,  comparative  data,  and  HCFA  monitoring  efforts  in the  report  to provide  context 
for our  findings.  However,  we chose  not  to largely  because  such  discussions  would  have 
over-extended  an already  lengthy  report.  Instead,  we cautioned  readers  about  the  nature 
and limitations  of the  data  presented,  and  have  included  the  bibliography  for  those 
interested  in more  detail.  All  things  considered,  though,  we  still  believe  that  the  three 
problem  areas  we  identi-fkd  deserve  further  examination. 
8
 ENDNOTES

1.  Medkare  Managed  Care  Contract  Report,   July  1,  1994,  prepared  by  Office  of

Managed  Care,  HCFA.

2.  Serious  health  problems  such  as,  broken  bones,  cancer,  hexrt  attack,  pneumonia  or

a stroke.

3.  The average  length  of enrollment  in the  sampled  HMO,S was  36  months  for

enrollees  and  29  months  for  disenrollees.

4.  An additional  concern  is that  these  indicators  are  based  only  on responses  from

beneficiaries  who  did  enroll  in an HMO.  We  cannot  know,  for  this  study,  the

experience  of those  who  considered  HMO  membership,  but  did  not  enroll.

5.  A complication  of payment  for  emergent  y care  is that  beneficiaries,

understandably,  dont  always  differentiate  between  emergency  care  and  urgent

care.  While  HMOS  will  generally  pay  for  any  required  emergency  care,  they  will

only  pay  for  unauthorized  urgent  care  outside  the  service  area.

6.  Some  literature  indicates  this  attitude  toward  the  older  patient  is a problem

generally  and  is not  necessarily  confined  to one particular  care  setting.

7.  Disabled/ESRD  disenrollees  also  seem  to be  disproportionately  represented  in their

stratum.  In  the  entire  sample  and  in the  enrollee  stratum,  the  weighted  proportion

of disabled/ESRD  beneficiaries  is 3 %.  Disabled/ESRD  disenrollees  account  for

8% of their  stratum.

8.  The disenrollees  (18%)  who  cited  administrative  reasons  @  are  not  included  in

the following  analysis.  Administrative  reasons  for  disenrollrnent  were  moving  out

of the HMO  service  area  (25 %),  their  HMOS  no longer  participating  as  a Medicare

risk HMO  or  in their  companies  retirement  plan  (6%),  or involuntary

disenrollments  such  as late premium  payments  or clerical  error  (3 %).  Disenrollees

could  select  more  than  1 reason.  Enrollees  described  disenrollment  reasons

because  they  either  planned  to  leave  their  HMOS  or  wanted  to  leave,  but  felt they

could  not.

9.  Before  the  House  Select  Subcommittee  on  Education  and  Civil  Rights  by  a

representative  from  the  National  Council  on Independent  Living.  Medicare  and

Medicaid  Guide,  No.  789,  Commerce  Clearing  House,  February  17,  1994,  p.  5)

10.  Brown,  Randall  S.,  Dolores  Clement,  Jerrold  Hill,  Sheldon  Retchin,  and  Jeanette

Bergeron,  Do  Health  Maintenance  Organizations  Work  for  Medicare?  Health

Care Financing  Review,  Fall,  1993,  15:1:7-23.

9
 il. I?enchansky,  Roy,  DBA,  and  J.  William  Thomas,  PhD,  The  Concept  of Access: 
Deftition  and  Relationship  to Consumer  Satisfaction,   Medical  Care,  February 
1981> 12:2:127-140. 
Thomas,  J.  William,  PhD,  and  Roy  Penchansky,  DBA,  Relating  Satisfaction  With 
Access  to Utilization  of Services,   Medical  Care, June  1984,  22:6:553-568. 
12.  The Penchansky  and  Thomas  five  dimensions  of access  co services  are: 
a.	 Availability  - the  relationship  of the volume  and  type  of existing  services 
(and  resources)  to the  clients  volume  and  types  of need.  It refers  to the 
adequacy  of supply  of medical  providers,  facilities  and  specialized  programs 
and  services,  such  as mental  health  and  emergency  care. 
b.	 Accessibility  - the  relationship  between  the  location  of supply  and  the 
location  of clients,  taking  account  of client  transportation  resources  and 
travel  time,  distance  and  cost. 
c.	 Accommodation  - the  relationship  between  the  manner  in which  the  supply 
resources  are  organized  to accept  clients  (including  appointment  systems, 
hours  of operation,  walk-in  facilities,  telephone  services)  and  the  clients 
ability  to accommodate  to these  factors  and  the  clients  perception  of their 
appropriateness. 
d.	 Afloralzbility  - The relationship  of prices  of  services  and  the providers 
insurance  (or deposit  requirements)  to clients  income,  ability  to pay  and 
existing  health  insurance.  Client  perception  of  worth  relative  to total  cost  is 
a concern,  as is client  knowledge  of prices,  total  cost  and possible  credit 
arrangements. 
e.	 Acceptability  - the  relationship  of clients  attitudes  about  personal  and 
practice  characteristics  of providers  to the  actual  characteristics  of existing 
providers,  as well  as to provider  attitudes  about  acceptable  personal 
characteristics  of clients.  In turn,  providers  have  attitudes  about  the 
preferred  attributes  of clients  or their  financing  mechanisms.  Providers 
may  be unwilling  to  serve  certain  types  of clients  or,  through 
accommodation,  make  themselves  more  or less  available. 
10
 APPENDIX  A 
Methodology  and  Demographic  Profile 
lhlethodoiogy 
This  studys  primary  focus  is the Medicare  beneficiaries  perceptions  of a risk  HMO 
experience.  Thus,  we collected  information  directly  from  beneficiaries  but  not  from  HMOS, 
their  staffs  or their  medical  records.  We  also  did  not  speciflcal,ly  ask  beneficiaries  about 
their  satisfaction  with  the  HMOS,  as the  concept  of satisfaction  is less  objective  than,  and 
sometimes  independent  of,  the  issues  of membership  in a Medicare  risk  HMO.  Since  the  law 
and  regulations  do not  clearly  delineate  what  full  access  to services  through  a Medicare  risk 
HMO  means,  we adapted  a deftition  from  literature.  11,12 We  exp~d~  thisdeffition 
to include  the role  of HMO  gatekeepers,  primary  physicians  or others,  in preventing  or 
facilitating  beneficiaries  receipt  of covered  services.  Operationally,  we divided  access  into: 
timeliness  of appointments;  service  restrictions;  incidence  of out-of-plan  care;  and  behavior 
of HMO  persomel  towards  beneficiaries. 
Using  HCFA  databases,  we  selected  a stratified,  random  sample  of 4,132  enrollees  and 
disenrollees  from  45 Medicare  risk  HMOS.  Of the  structured  surveys  mailed  tcaeach 
sampled  beneficiary,  a total  of 2,882  surveys  (1,705  enrollees  and  1,177  disenrollees)  were 
returned  and  deemed  usable.  The  weighted  sample  approximates  the distribution  of emollees 
and disenrollees  in the  universe  (97%  vs.  3 %).  Because  of this  imbalance,  we initially 
analyzed  the two  groups  separately  and  then  compared  their  responses.  Throughout  the 
report,  percentages  are  based  on the  number  of responses  to each  question.  We  also 
analyzed  sub-populations  of enrollees  and  disenrollees.  (See  Table  on  next  page  for 
demographic  profde  of respondents.) 
A-1
 Demographic  Profile  of Respondents 
(Weighted  Data) 
.  -
TOTAL  POPULATION  DISENROLLEES  1 
GENDER 
----= 
Female  60%  (666,049)  53%  ( 15,065;/ 
Male  40%  (446 ,205)  47%  (13,139)  40%  (433,067) 
RACE/ETHNICITY 
----k
White  90%  (991 ,084)  88%  (24,872) 
Non-White  7%  (83 ,684)  12%  (3,:332)  7 %  (80:;52) 
Unknown  3%  (37,486)  o  3%  (37,486) 
. 
.AVERAGE  AGE  74 Years  73 Years  74  Years 
... 
EDUCATION 
<  Than High School  24%  (274, 156)  20%  (5,683)  2594  (268,473) 
High School Diploma  29%  (318,440)  22%  (6,238)  29%  (312,201) 
>  Than High School  43%  (474,317)  49%  (13,778)  42%  (460,539) 
No Response  4%  (45,342)  9%  (2,504)  4%  (42,838) 
-
MEDICARE 
CATEGORY 
Aged  97%  (1,078,445)  92%  (25 ,907)  97%  (1,052,538) 
DisablecUESRD  3 %  (33,809)  8%  (2,296)  3%  (31,513) 
COMPETITIVE  AREA 
Competitive  63%  (700, 103)  53%  (14,878)  63%  (685,225) 
lNoncompetitive  37%  (412,152)  47%  (13,325)  37%  (398,826) 
HMO  EXPERIENCE 
Prior Experience  14%  (154,069)  21%  (5,997)  14%  (148,072) 
INOExperience  82%  (906,961)  71%  (19,905)  82%  (887,056) 
No Response  d%  (51,226)  8%  (2,302)  4%  (48,923) 
AVERAGE  LENGTH 
OF TIME  IN H~MO  36 Months  29 Months  36 Months 
SERIOUS  HEALTH 
CONDITIONS 
2 +  ~ondition~  6%  (61,003)  5%  (1,254)  6%  (59,749) 
1 condition  24%  (265,866)  22%  (6,153)  24%  (259,713) 
None  60%  (669,619)  58%  (16,440)  60%  (653 , 180) 
No Response  10%  (115,767)  15%  (4,357)  10%  (111,410) 
1 
A competitive area is a county in which 2 or more of glJ Medicare  risk HMOS,  not just sampled HMOS, 
provide services.  13e~eficiaries were then matched to counties by zip codes  of their mailing address. 
2 
Health conditions  are seLf-reported, and are for example,  broken bones,  cancer,  heart attack, pneumonia  or 
stroke. 
A-2