Out-of-plan use by Medicare enrollees in a risk-sharing health maintenance organization.
Haglund, Claudia L
Date of Pub
Diehr, Paula; Johnston, Ric; Martin, Diane P; Richardson, William C
In this study, we analyzed the cost and volume effects of a waiver that eliminated lock-in restrictions on out-of-plan use
in a health maintenance organization (HMO) with a Medicare risk-sharing contract. We compared out-of-plan cost and number
of claims during a 15-month base line period when the lock-in was in effect, with a 24-month waiver period when the lock-in
was removed. The results demonstrate that average per capita cost and claims increased significantly for both Medicare Part
A (hospital insurance) and Part B (supplementary medical insurance) out-of-plan services during the waiver. Self-referred
out-of-plan use normally prohibited by lock-in, accounted for 20 percent of all out-of-plan costs during the waiver and 57
percent of the increase in out-of-plan costs from the lock-in to the waiver. The combination of risk-sharing and lock-in provisions
holds promise as a method for reducing expenditures for the Medicare program.
Health Maintenance Organizations : Costs and Cost Analysis : Emergencies : Health Services/utilization : Medicare/utilization
: Pilot Projects : Statistics : Support, U.S. Gov't, Non-P.H.S. : Washington