Academic journal article Health Care Financing Review

Shifting the Paradigm: Monitoring Access in Medicare Managed Care

Academic journal article Health Care Financing Review

Shifting the Paradigm: Monitoring Access in Medicare Managed Care

Article excerpt


Managed care currently plays a small but growing role in the Medicare program. At the end of 1995, 10.7 percent of Medicare beneficiaries were enrolled in managed care plans (Physician Payment Review Commission, 1996). Enrollment is heavily concentrated in plans that are paid under a risk contract to deliver services in exchange for a fixed payment per enrollee.(1) Enrollment in those plans has increased more than 30 percent since 1994, and the proportion of beneficiaries who obtain medical care through capitated plans is expected to continue to increase. Such expectations are fostered both by the increasing proportion of enrollees with managed care experience and by growth in private health plan participation in the risk program. In addition, increased beneficiary enrollment would be anticipated under policy proposals to expand the range of health care delivery alternatives available under Medicare.(2) Proposals to do so have been endorsed recently by both the Administration and by Congress.

The growth of managed care presents a number of challenges for Medicare policy, not the least of which is how to continue to fulfill the program's responsibility to ensure beneficiaries' access to care. In this article, we consider the implications of Medicare managed care growth for efforts to monitor beneficiaries' access. Systems currently used for monitoring access need to be revised, and data and measures suitable for monitoring will need to be developed. Ultimately, under a Medicare program that offers a wide array of health care financing and delivery options, monitoring efforts will need to be unbiased for the mode of health care delivery.


Ongoing monitoring efforts provide information on Medicare beneficiaries' ability to obtain medical care. Annual reports on beneficiaries' access are produced by both HCFA and PPRC. These monitoring efforts were mandated by Congress to track the impact of the Medicare fee schedule (MFS) and to provide information for updating the conversion factor under the process for setting Volume Performance Standards (Health Care Financing Administration, 1995b; Physician Payment Review Commission, 1995). Therefore, by design, these efforts have focused on access in FFS Medicare.

Policy interest and the availability of beneficiary-level Medicare data have supported numerous studies using a variety of methods for analyzing beneficiaries' access to care in the traditional Medicare program. In this section, we describe the dominant theoretical approach to evaluating access that has guided past studies, and the measures and data that have been used in both one-time studies and ongoing efforts to monitor access.

Conceptual Framework

Aday, Andersen, and colleagues established the conceptual framework for most subsequent analyses of access to care (Andersen and Aday, 1978; Aday and Andersen, 1981). In these researchers' view, access is a function of three categories of variables: (1) predisposing factors, such as personal resources, education, race, and age; (2) enabling factors, such as the availability of providers in a community, an individual's insurance coverage, and existence of a regular source of care; and (3) finally, an individual's need for health care, as indicated by health status and symptoms.

Using this framework, the effects of these variables on access to care can be observed through measurement of health care services utilization. Studies of access have lent support to this framework by demonstrating variation in the use of services that could be explained by differences in health status, sociodemographic factors, and characteristics of the health care market.

Although most studies of access focus on utilization as a measure of realized access, some studies have taken a different approach. For some researchers, access is a relatively narrow concept. …

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