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- W219550015 abstract "The growth of managed care must be assessed in terms of whether it makes a difference in the quality of healthcare provided to older Americans and whether it meets their needs and expectations. Assessments of managed care as a whole are indeed difficult. First, there are different types of managed care plans, including different kinds of health maintenance organizations (HMOs), preferred provider organizations (PPos), and the like. Second, within each type of plan, the performance of one specific managed care organization may vary compared to another. And in some more mature managed care markets, where care delivery systems have become better organized (for example, Los Angeles and Minneapolis), quality can vary even within the same plan, depending on which provider group is the focal point for care received. With the passage of the Balanced Budget Act in I997, the landscape of managed care options is about to get a lot more varied, and probably a lot more confusing, for many older Americans. Many HMOs are already offering a new point of service (Pos) option, which covers at least part of the cost of providers who are not included in the HMO network. The Medicare + Choice program will add a PPo option, in which copayments are lower when participating providers are used, and will also permit provider sponsored organizations (PSOs), HMOs started by physicians and hospitals, to enroll beneficiaries if they meet the standards of the federal government's Health Care Financing Administration for financial solvency and other characteristics rather than state HMO licensing requirements. The full implications of these new options cannot yet be assessed. We do not yet know exactly what regulations will govern these options, how insurers and providers will respond, what plans will be offered, and where they will be offered. However, even today, the ability to choose a Medicare HMO or similar coverage has profoundly changed the decision context facing older Americans, in a way that makes concerns about quality far more central. In a fee-for-service environment, beneficiaries who could afford to purchase supplemental coverage, or who had access to such coverage through their own or their spouse's former employer, had to choose a health insurance plan. They chose their providers separately. The issue of healthcare quality emerged primarily in the context of selecting providers. In contrast, when an older person chooses an HMO or other managed care options, he or she is simultaneously choosing insurance and providers. In addition, the person is choosing a system of care with rules and procedures that govern what must be done to gain access to care and often even what services or products will be available. For example, one of the great advantages of most managed care plans for older people is that they cover prescription medications. The elimination of financial barriers to obtaining medications essential to managing chronic conditions and treating acute episodes can certainly have a positive effect on quality. However, most managed care plans have a specific list of drugs they cover; if a drug that a patient and his or her physician believe is needed is not on that list, obtaining that drug can be difficult, if not impossible. More than ever, quality of care is at stake in the healthcare coverage decisions made by older Americans. This paper will discuss how older Americans define quality and the factors that seem to influence satisfaction with their managed care plans. The issue of quality as related to coverage, provider choice, plan design, and cost will be addressed. We will also discuss current initiatives to measure quality and satisfaction in Medicare HMOs and how those efforts might influence both internal quality improvement efforts by managed care plans and the quality and availability of information to help consumers make intelligent choices. Finally, we will identify some of the critical issues that must be addressed if managed care is to fulfill its potential as a source of well-coordinated, flexible, and cost-effective care for older Americans. …" @default.
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- W219550015 title "Satisfaction and Quality in Managed Care for Older People" @default.
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