As of mid-1994 there were nine replications of the On Lok model operating under dual capitation payments as sites in the Program of All-inclusive Care for the Elderly (PACE). A tenth site had begun operating under capitation, but was unable to remain viable. The present descriptive study documents the growth and development of the first seven of these sites, all that had been operating under capitation during 1992. Comparisons among these sites and with On Lok are presented in the areas of organizational structure, client characteristics, approaches to case management, service delivery options, and financing. There is considerable variability in the implementation of the PACE model. Combined Medicare and Medicaid capitation monthly payments range from $2,147 to $5,973. These seven PACE sites (excluding On Lok) served a total of 888 current clients at the end of 1992, after a cumulative 136 months of experience under capitation. The very slow enrollment rates may imply that the target clients are less enthusiastic about this model than are its architects. The client selection process may suggest niche-marketing or skimming, but not the full representation of the nursing home population in their states. Given both the slow enrollment and the niche-marketing (the benevolent term) or skimming (the pejorative term) that has occurred, caution about the long-term viability of the PACE model may be warranted.

Visits to the emergency department (ED) are costly, and because some of them are potentially avoidable, some types of ED visits also may be indicative of poor care management, inadequate access to care, or poor choices on the part of beneficiaries. Billings and colleagues developed an algorithm to analyze ED visits and assign probabilities that each visit falls into several categories of appropriateness. The algorithm has been used previously to assess the appropriateness of ED visits at the community or facility level. In this analysis, the authors explain how the Billings algorithm works and how it can be applied to individual physician practices. The authors then present illustrative data from 2 years of Medicare claims data from 5 states. About one third of ED visits are deemed appropriate, and about half could have been treated in a primary care outpatient setting. Another 15% were deemed preventable or avoidable.

Objective. To provide national estimates of the effect of out‐of‐pocket premiums and benefits on Medicare beneficiaries' choice among managed care health plans. Data Sources/Study Setting. The data represent the population of all Medicare+Choice (M+C) plans offered to Medicare beneficiaries in the United States in 1999. Study Design. The dependent variable is the log of the ratio of the market share of the jth health plan to the lowest cost plan in the beneficiary's county of residence. The explanatory variables are measures of premiums and benefits in the jth health plan relative to the premiums and benefits in the lowest cost plan. Data Collection Methods. The data are from the 1999 Medicare Compare database, and M+C enrollment data from the Centers for Medicare and Medicaid Services (CMS). Principal Findings. A $10 increase in an M+C plan's out‐of‐pocket premium, relative to its competitors, is associated with a decrease of four percentage points in the jth plan's market share (i.e., from 25 to 21 percent), holding the premiums of competing plans constant. Conclusions. Although our price elasticity estimates are low, the market share losses associated with small changes in a health plan's premium, relative to its competitors, may be sufficient to discipline premiums in a competitive market. Bidding behavior by plans in the Medicare Competitive Pricing Demonstration supports this conclusion.

Research Objective. To evaluate the effect of the Health Insurance Flexibility and Accountability (HIFA) demonstrations on the rate of uninsured. The policy purpose of the HIFA demonstrations is to encourage "new comprehensive state approaches" that will increase the number of insured. HIFA interventions include changes in benefit packages, eligibility rules for public programs, and state subsidization of private health insurance premiums. Some states emphasized private insurance (premium assistance), whereas others placed greater emphasis on expanded eligibility for public insurance. Data Sources/Study Setting. Data were drawn from the Current Population Survey from 2000 to 2007. The target populations for the HIFA waiver demonstrations consisted of individuals who were eligible for the HIFA waiver demonstrations in demonstration states. Study Design. The estimation approach was a probit model using a difference-in-differences approach. Principal Findings. In states that fully implemented their HIFA waiver, HIFA increased the rate of insurance coverage by 6.4 percentage points on average in the targeted adult population, suggesting that approximately 118,848 adults gained health insurance due to HIFA. Total HIFA adult enrollment in the six states studied was 280,739. The effect size varied by state, with Maine having the largest effect and Illinois the smallest. The results were robust to different specifications of the control group. Conclusions. Our findings suggest that public insurance initiatives that provide states with flexibility regarding eligibility and plan design are a viable policy approach to reducing uninsurance rates. Key Words. Under HIFA, states were allowed to subsidize private health insurance premiums for either SCHIP or Medicaid enrollees (the latter under the Medicaid Health Insurance Premium Payment program) (Zabaza 2003). Subsidies for private health insurance premiums were intended to leverage private funds to help cover the uninsured and overcome the "welfare stigma" associated with public insurance programs for low income people. The Centers for Medicare and Medicaid Services (CMS) provided "strong encouragement" to states to further integrate, or at a minimum coordinate, Medicaid and SCHIP funding with private health insurance options (including both group and individual insurance). Flexibility was provided for premium assistance options, in terms of benefits and cost sharing. States also were allowed to use Federal funds to develop and subsidize privately offered health insurance products that groups or individuals might purchase with a public subsidy. A total of fifteen states Table 1). The purpose of our analysis is to determine whether adult enrollment in HIFA programs had the effect of reducing the uninsurance rate in HIFA states. The HIFA programs would reduce the uninsurance rate as long as HIFA enrollees were drawn from the ranks of the previously uninsured rather than from individuals previously enrolled in public or private health insurance programs. Thus, our analysis ...

This study suggests that simply providing a Medicaid card or private indemnity insurance card is not enough to ensure access to care. Future initiatives also need to consider the structure of the delivery system, especially the availability of a medical home (with adequate after-hours care), as well as the impact of discontinuous insurance coverage on access to and continuity of care.