Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

BENEFICIARY PERSPECTIVES OF


MEDICARE RISK HMOS


Summary Report 

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MARCH 1995 

OEI 06-91-00736 
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 President’s Council on Integrity and Efficiency. 

FININNGS 

Generally, beneficiary responses indictie Medicare risk lZWOs provided axiequale service 

access for most benejiciun”es 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 dun”ng 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 Whi) had comparable health 

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 beneficiary’s 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% didn’t know they have the right to appeal the HIIO’S 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 benefician”es. 

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 pn”mary and speciu.lty care, to seek out-of-plan care 

and to report their HMOS’ or pn”mary docto~’ unsympdtetic behan”ors. 

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. 

k Out-of-plan care: Excluding dental, routine eye, and emergent/urgent care, 7% 

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 outof-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, 

didn’t refer them to specialists when necessary, and didn’t 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 remaz”nder 

voiced more cn”ticism of their HMO expen”ence; 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 HMO’s 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 h“mely 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 oj”primary 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: 

b didn’t like the choice of primary HMO providers:


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 HCFA’S 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 report’s 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. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

9. 

10. 

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


Managed Care, HCFA.


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


a stroke.


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


enrollees and 29 months for disenrollees.


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.


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


understandably, don’t 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.


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


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


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.


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.


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)


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 client’s 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 client’s 

ability to accommodate to these factors and the client’s perception of their 

appropriateness. 

d.	 Afloralzbility - The relationship of prices of services and the providers’ 

insurance (or deposit requirements) to client’s 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 study’s 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 tca each 

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 

Male 

RACE/ETHNICITY 

White 

Non-White 

Unknown 

.AVERAGE AGE 

EDUCATION 

< Than High School 

High School Diploma 

> Than High School 

No Response 

MEDICARE 

CATEGORY 

Aged 

DisablecUESRD 

COMPETITIVE AREA 

Competitive 

lNoncompetitive 

HMO EXPERIENCE 

Prior Experience 

INOExperience 

No Response 

AVERAGE LENGTH 

OF TIME IN H~MO 

SERIOUS HEALTH 

CONDITIONS 

2 + ~ondition~ 

1 condition 

None 

No Response 

1 A competitive 

““---”-= 60% (666,049) 53% ( 15,065;/ 

40% (446 ,205) 47% (13,139) 40% (433,067) 

90% (991 ,084) ---””’-k 88% (24,872) 

7% (83 ,684) 12% (3,:332) 7 ‘% (80:;52) 

3% (37,486) o 

—. 3% (37,486) 

74 Years 73 Years 74 Years .——.. 

24% (274, 156) 20% (5,683) 2594 (268,473) 

29% (318,440) 22% (6,238) 29% (312,201) 

43% (474,317) 49% (13,778) 42% (460,539) 

4% (45,342) 9% (2,504) 4% (42,838) ——-

97% (1,078,445) 92% (25 ,907) 97% (1,052,538) 

3 % (33,809) 8% (2,296) 3% (31,513) 

63% (700, 103) 53% (14,878) 63% (685,225) 

37% (412,152) 47% (13,325) 37% (398,826) 

14% (154,069) 21% (5,997) 14% (148,072) 

82% (906,961) 71% (19,905) 82% (887,056) 

d% (51,226) 8% (2,302) 4% (48,923) 

36 Months 29 Months 36 Months 

6% (61,003) 5’% (1,254) 6% (59,749) 

24% (265,866) 22% (6,153) 24% (259,713) 

60% (669,619) 58% (16,440) 60% (653 , 180) 

10% (115,767) 15% (4,357) 10% (111,410) 

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