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Health Tracking

MARKETWATCH

Geography And Destiny: Local-Market Perspectives On Developing Medicare Advantage Regional Plans

Abstract

 
The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 established regional preferred provider organizations (PPOs) as a new private-plan option for beneficiaries in the Medicare Advantage (MA) program, starting in 2006. Developing network-based Medicare products uniformly priced across statewide or multistate regions presents unprecedented challenges and opportunities for health insurers. We held discussions with local health plan and hospital informants in six of the twelve Community Tracking Study (CTS) communities to obtain their perspectives on key considerations in evaluating whether they can and will offer regional PPO products under the MA program.

Drawing on the perspectives of local observers from interviews conducted during summer 2004, researchers from the Center for Studying Health System Change (HSC) explored private health plans’ concerns about the formation of the regions and the challenges they expect to face if they choose to develop networks and launch products that will serve Medicare beneficiaries in geographic regions that are larger and broader than any the plans have ever attempted. In effect, the study investigated what plans believe they will have to do to go boldly where no plans have gone before. Here we detail the findings from the interviews and identify the key issues to watch as the development process unfolds.

Regional plans in MMA. MMA was designed to achieve five goals related to private MA plans: (1) maximize beneficiaries’ access to private plans; (2) encourage plans to enter areas not served by MA plans; (3) promote vigorous competition among MA plans; (4) expand the types of private plans in Medicare; and (5) reduce long-term cost growth.² A key policy decision affecting the achievement of the goals was selection of the number of U.S. market regions and their geographic boundaries. The legislation gave the HHS secretary discretion to designate from ten to fifty regions.

Regional plans are expected to be preferred provider organizations (PPOs) that will compete with local (county or subregional) MA health plans, including health maintenance organizations (HMOs), PPOs, and private fee-for-service plans.³ MMA requires competitive bidding in which regional plans must bid a single price for an entire region, while local plans bid a single price for each county they wish to serve. Government payments to regional plans will be set equal to a benchmark premium, blending regional cost-of-care factors and adjusted for beneficiary risk. Beneficiaries will pay the difference between the bid and the benchmark if the bid exceeds the benchmark. The tight timetable for development of regional plans, to operate by January 2006, requires that bids be submitted by June 2005 and awarded by September 2005.⁴

To make private health plan participation more attractive, MMA will share financial risk for the first two years and will offer access to "stabilization" and "network adequacy" funds. More notably, local HMO plans received large payment increases, which have made their Medicare products more profitable. In many markets, these payments now far exceed what Medicare pays for beneficiaries remaining in the traditional program.⁵ Large payment increases to local plans are likely to influence their interest in participating as regional plans. However, sizable payment increases introduced in the face of rising federal deficits raise questions about whether the increases are both prudent and sustainable.⁶

Study focus and approach. Although many health insurance plans have offered statewide and multistate products to employers, virtually none has offered Medicare managed care products statewide, let alone in multiple-state regions. Many health plans sharply reduced the scope of their county-based markets after the Balanced Budget Act (BBA) of 1997 in response to lower Medicare payment rates. MMA and its regional PPO architecture require plans to weigh many factors in deciding whether to participate and to undertake the key challenges of developing products and networks, doing cost preparations for bidding, and developing the care and cost management techniques needed to be successful. Whether MMA’s sizable concessions made to private plans will encourage them to tackle these challenges is a critical policy question.

With the support of the Robert Wood Johnson Foundation, HSC has been conducting in-depth tracking of local-market developments in twelve markets across the country since 1996, through telephone and on-site interviews with representatives of the principal health care sectors.⁷ This study was carried out during summer 2004 through discussions with past HSC respondents in six of the twelve markets. The markets were selected based on variation in prior experience with Medicare managed care products, and, as previously detailed, they include communities with the highest managed care penetration levels in the country, as well as ones with no Medicare-participating health plans.⁸

Discussions focused on (1) exploring the challenges of developing commercial networks and products across broad geographic areas; (2) assessing how that experience relates to the development of regional PPO products under MA; and (3) understanding the relationship between size of region and likelihood of participation and profitability. Participants included health plan executives responsible for network development, marketing, and Medicare products and managed care contracting staff of major hospital systems. Markets are not identified to preserve confidentiality.

Findings

Top Findings Issues To Watch NOTES

 
Several areas of concern stood out for the health plan executives as they discussed the issues outlined above.

Challenge of entering markets not of their own choosing. The importance of the regions’ size and geographic boundaries was evident, because most plans are accustomed to choosing the markets in which they develop networks and offer and price commercial products. Plan respondents attached considerable importance to what they called "natural markets," meaning those that conform to well-established employment and residential patterns, as well as distribution of health care providers and referral configurations. Respondents readily acknowledged selectively entering preferred markets and avoiding others where prospects for new business are limited or provider network development is difficult or costly. In fact, many plans—with the exception of Blue Cross and Blue Shield (BCBS) plans—struggle to offer network-based products statewide, typically avoiding rural areas where they encounter minimal provider competition. Blue plans differ particularly because of their larger local memberships. In addition, licensing agreements to sell certain Blues products require that they have provider networks in place across the entire franchise area.

Encouraging plans to "engage in unnatural acts," as one observer phrased offering products across a large and diverse geographic region, is particularly at variance with past approaches to Medicare risk/Medicare+Choice (M+C) offerings. Entry has been voluntary at the county level, with plans carefully selecting the counties within a state that present the best opportunities to offer a profitable product. Plans initially expanded and then contracted their participation into compact geographic regions as opportunities for profitability contracted with changes in the payment formula. The county-based payment system ensures reasonable homogeneity in cost experiences and enables plans to determine profitability on a relatively precise basis to support decisions to expand and contract. Many plans modulate revenues by adjusting enrollees’ premiums to reflect cost-of-care differences across contiguous counties with different payment levels. Even within a single metropolitan area, plans might serve some counties while avoiding others, based on how payment rates compare with costs. Plan respondents viewed the possibility of statewide or larger regions as depriving them of the maneuverability that has enabled them to be profitable as local Medicare plans.

Interplay of product and network development. Plan and hospital respondents confirmed the well-worn managed care axiom: No lives means no leverage; no leverage equals no network; no network results in no product; and no product leads to no lives, and so on. To break into this cycle, plans will have to launch MA PPO products built on networks based on expectations about future enrollment with only limited leverage, causing concern about their ability to come up with a favorably priced bid. Notably, observers indicated that such a strategy was not uncommon in the commercial market during the most successful era of managed care, when price competition among plans was fierce and providers offered discounts with the expectation that patients would be steered to them. In effect, product pricing drove network contracting.

But network executives noted that a "sea change" has occurred and a "new reality" has set into providers’ negotiations for commercial plans. Provider consolidation, constrained capacity, and increased resolve in negotiations make providers less willing to discount their prices, and pressure from purchasers for broader networks has undermined threats of network exclusion.⁹ Most plans have expanded their networks in recent years with higher payments. Others have ceased to offer restricted network products in non–core markets where they have limited leverage or have discontinued them altogether. Still others have grown reliant on rental networks to achieve coverage in more remote geographic areas. This means paying an access fee to use networks assembled by others, even though such networks typically have only slender discounts. In creating MA PPO networks, added to these problems is the fact that since regional PPO participation under MA will be voluntary for beneficiaries and providers, providers will continue to have opportunities to see their Medicare patients in traditional fee-for-service arrangements, which will further undermine plans’ ability to compel network participation. In addition, a number of plan and hospital respondents expressed concern that past problems with plan and provider participation in M+C has sown seeds of skepticism about the sustainability of the new regional PPO product and the wisdom of network affiliation in Medicare products.

Leap of faith in product costing and bid preparation. Notwithstanding these concerns, most plan respondents believed that a regional bid price can be produced that could make these MA PPO products attractive to beneficiaries, particularly for those with Medigap products that have many limitations in terms of benefits and costs.¹⁰ If the benefit design is attractive and the network is adequate, plan respondents anticipate that membership will grow and will ultimately improve plans’ negotiating leverage and providers’ willingness to participate. Respondents also pointed out that they have experience in developing cost estimates for statewide employers such as state government agencies or utility companies, which have widely dispersed workforces using services in multiple markets. It is common to develop regional cost estimates for standard benefit packages and then give the employer the option of choosing regional variation in employee contributions or adopting a blended, group-wide rate. However, many of these large employers are self-insured, and the plan bears no medical cost risk.

Congress’s desire to promote availability of private plans in rural areas not previously served was seen as laudable, but troublesome, by plan respondents. They underscored that lack of population density and minimal provider competition are structural impediments to making managed care products profitable, and regional MA plans will struggle to deal with them. Rural hospital monopolies are a problem even for the largest of plans, and discounts from these facilities are largely token. Provisions in MMA for subsidies to contract with these providers to meet network adequacy standards may help, but some plan respondents said a preferred approach would have been to allow plans to impose Medicare prospective payment system (PPS) rates on hospitals with which they could not come to terms.¹¹ Other respondents suggested that despite expectations of paying more for provider participation in some areas, the overall effect will be modest, since a relatively small portion of beneficiaries reside in these areas that are expected to be high-cost.

Cost and care management problems and prospects. Respondents asserted that requiring plans with Medicare HMO experience to cover larger regions than they now serve will dilute their ability to manage beneficiaries’ costs and care. In part this reflects the fact that M+C markets have been compact and the provider networks of most M+C HMOs have been narrower than commercial networks, often having some elements of risk sharing built into provider compensation. A number of Medicare HMO respondents reported that they have negotiated rates of payment with providers below traditional Medicare physician or hospital payments. They attributed this to competitive dynamics in their local market, high HMO enrollment penetration, and physicians’ desire to accommodate their patients’ preferences. But these plan respondents all reported that current pressures are making it more and more challenging to sustain these arrangements, and that in some cases, the narrower networks are a function of provider withdrawals. Most plan-contracting executives worried that PPOs’ more limited ability to steer patients to providers means that they will be unlikely to achieve such favorable terms.

Respondents believed that regional PPOs will have less ability to use conventional medical management techniques than local HMOs if regions are large. This perspective may reflect skepticism about the cost management prospects of a PPO product as it reflects concern about region size. One observer suggested that because PPOs do little medical management, they are even more reliant on rate negotiation as a cost-saving mechanism. Having to serve broad regions where they have few commercial members will deprive plans of negotiating leverage. A hospital respondent confirmed this concern by noting that his facility would consider participation in a PPO network under MA if he felt that he could get better payments from private plans for cardiovascular services such as angioplasty with insertion of stents, which is currently "underpaid" by Medicare. Other plan respondents with well-established PPO products, including especially BCBS plans, felt that the product could incorporate state-of-the art disease management programs and predictive modeling techniques. But they noted that the more extended the geographic expanse of the region, the less impact these PPOs will have on individual providers’ behavior in areas where they do not expect to have substantial market share.

The uncertain Medicare market. Plan respondents were particularly focused on the many sources of uncertainty that pervade the Medicare line of business. They identified such concerns as the proliferation of product options and their competitive implications, selection dynamics as beneficiaries choose among options, uncertain status of future Medigap offerings, impact of the Part D drug benefit, and the sustainability of substantial rate increases delivered in MMA’s first phase. For some plans, sharply improved payment rates were clearly rejuvenating interest in Medicare. These plans were adding counties to their existing markets or expanding to new markets with local HMO or PPO products. For some plans, this could be the first step toward regionwide plans, while for others, local plan status was attractive enough that they expected to concentrate on local products, address the addition of the Part D drug benefit in 2006, and forgo regional plan opportunities. For these plans, the major preoccupation was on maintaining a level playing field of competition between local and regional plans. Some local HMOs suggested that the Medicare PPO demonstration had deviated from this goal and could be a portent of further accommodation made to stimulate the development of regional PPOs under MA.

Other observers were concerned about how selection dynamics among product options for beneficiaries were going to be made more complicated and less predictable as MMA was fully implemented. While acknowledging that risk adjustment in Medicare payments should in theory negate selection effects, many plans remained skeptical about the precision of these techniques. New products could alter typical patterns of Medigap policies, which appeal to older and affluent beneficiaries, and HMOs, which attract younger and poorer people. Likewise, enrollees’ health status could shift with the availability of drug benefits to complement traditional Medicare, with or without other supplements. Plan respondents contended that they were uncertain whether competition from freestanding drug plans would make bid preparation for large regions with multiple product offerings more difficult. A final concern voiced by several observers was that the "rules of the [Medicare] game can always change."

Issues To Watch

Top Findings Issues To Watch NOTES

 
The compressed implementation schedule meant that plans had considerable planning under way pending the decision in December 2004 that designated the twenty-six regions, to enable them to meet the bid deadline of June 2005. As the plans that choose to participate reach that date, several issues raised in the interviews merit attention.

Number of regions and implications for players. The selection of twenty-six regions, most of which are single states, appears to bode well for participation. Designating most large states their own region makes choice of participation easier for those plans that already have contracted networks for most or all of an entire state. Plan respondents believed that in most cases, single states were large enough so that adequate numbers of beneficiaries could be ensured, to justify product development. States that evoked the largest concerns were sparsely populated ones in the upper Midwest and Far West that are now combined into multistate regions. In all cases, combined states are contiguous, have considerable commonality in terms of regional referral centers corresponding to at least one of the characteristics of natural markets, and, ostensibly, have cost homogeneity. However, large urban-rural differences still exist within these regions, and many urban areas will be split by regional boundaries, which confirms plans’ concern about serving "unnatural" markets.

The Blue view. The Blue Cross and Blue Shield Association (BCBSA) was very public in its advocacy on behalf of its licensees for single-state regional plans.¹² The Blues’ posture seems to be of singular importance to the success of the MA regional plan strategy, given that they (1) have the most complete statewide networks across the country; (2) enjoy the best price discounts with providers in most states; (3) offer the leading PPO products in most markets; (4) are the dominant players in the Medigap market throughout much of the nation; and (5) enjoy enormous brand-name recognition with seniors. To a large extent, the regional structure accommodates their major concerns while also presenting these plans with some delicate issues to resolve. Most of the largest Blue plans will be able to participate on a single-state basis. Some multistate regions conform to ownership by a single corporate parent, such as WellPoint’s ownership of the local Blue plans in Indiana and Kentucky that form MA PPO Region 13. All Blue plans noted that they would have to negotiate new contracts with their hundreds of thousands of network hospitals and physicians for their Medicare products.

Another challenge for Blue plans will be creating new joint ventures necessary to bear risk in multistate regions or within single-state regions with multiple Blues license holders, such as Pennsylvania and New York. This may be more difficult in regions where Blue plans have different ownership structures (profit/not-for-profit status) and a history of competitive rivalry. For example, three different Blue plans are in the Virginia–North Carolina region. One of these plans is investor owned and part of WellPoint, whereas the other two are nonprofits that have failed in recent efforts to convert to investor-owned status, including CareFirst of Maryland, which WellPoint attempted to acquire.¹³ The three licensed brand holders will have to find a mutually acceptable arrangement to sell a Blue-brand plan across the region. The attractiveness of an offering by any one of the three plans could be greatly diminished if it is not a branded product.

Pursuing regional MA plans versus local options. Many local plans have expanded the counties in which they are offering either local HMO or PPO products in the year since the lucrative new payment rates in MMA were implemented. In some cases, this has meant a return to markets previously abandoned in the wake of the BBA. Other plans portrayed these decisions as a way to gain presence in a market with a local plan to preempt competing plans from targeting that market for entry as either a local or regional player. It will be important to track whether the more manageable implementation and predictable profitability of local plans are so compelling that plans that might have aspired to regional-plan status decide to remain local.

Local HMO plans with long-standing involvement in Medicare strongly asserted that they will be able to negotiate better provider terms and manage care more effectively than looser, more far-flung regional PPOs. They also believe that they will be able to parlay tighter relationships with providers to implement and manage more successfully the Part D benefit that will be added to the basic benefit package in 2006. These plans have had extensive experience with drug benefits for Medicare beneficiaries and believe that they can already attest to the advantage of integrating medical and pharmaceutical services. However, their proficiency in managing care may also make them more vulnerable to attracting Medicare beneficiaries with greater needs than regional PPOs attract. These local HMO plans were hopeful that risk adjustment will allay some of this concern, and they were particularly adamant that PPOs be subjected to similarly aggressive oversight of marketing and enrollment practices as HMOs have been in the past, underscoring the level-playing-field concern raised earlier.

Strategic posture of multiproduct firms. The fervor of Congress’s commitment to private-plan options for Medicare beneficiaries creates great opportunities for firms eager to mine the senior market. Although a number of firms had signaled their intent to offer a broad array of senior products, the BBA and reversal of fortune for the M+C options slowed this movement. It now appears that several plans are poised to launch a menu of options for Medicare beneficiaries including MA local and regional plans, freestanding prescription drug plans, and Medigap policies to individuals as well as additional configurations for employer-sponsored retiree coverage. These plan respondents said that it is important to offer products that allow seniors to sort themselves out into arrangements and benefit designs that correspond to the diversity of the market in terms of age, health, socioeconomic status, and comfort level with certain product designs, such as restricted networks.

For some plans, such as those with strong Medigap products, broadening offerings is crucial to fending off competitors and protecting market share. For others, new product offerings may be able to reach those beneficiaries for whom the HMO is not acceptable, particularly in markets where HMO penetration has plateaued. Others are so uncertain of the impact of the Part D benefit, and the freestanding plans that might offer it, that they will likely enter that market to avoid being left out of it. In all cases, plan respondents openly expressed concern about "cannibalizing" their existing Medicare products and about an excessive number of players and products competing for a fixed number of beneficiaries. But they also felt that the market is just too large not to pursue it. Because many of these plans are among the nation’s largest, their decision to offer products and which products to offer could have a large bearing on the shape of the Medicare program of the future.

Employer-sponsored and Medicare supplement transitions. Who is likely to enroll in the regional MA PPOs when they go to market? Most observers expect that the current local-plan enrollees will remain largely where they are and that the growth of these local plans will pick up in the year prior to launch of the PPOs. Some growth in local plans may come from those large employers that continue to sponsor retiree benefits. However, many large employers may prefer the simplicity of giving retirees access to regional, network-based options such as PPOs that have broader geographic coverage and less variability than local HMOs. For health plans vying for the active population of these employers, offering regional PPOs may be a useful strategy to win or retain accounts. Moreover, many large employers have become disenchanted with the Medicare HMO program because of its precipitous decline after the BBA, so they might find the PPO option more palatable. But they are also likely to be skeptical of a new product and might hesitate to embrace it in its early years.

More certain enrollment in regional PPOs is likely to come from beneficiaries with Medigap coverage that plans feel can be enhanced in a PPO design. Integrating a drug benefit can boost the appeal of these products, particularly since the Medigap policies with drug coverage will not be permitted to enroll new beneficiaries. It is likely that plans with large Medigap enrollment will try to defend their market share and, in so doing, devise products and marketing campaigns that could accelerate enrollment in the new PPO offerings. Conversely, some of the plan executives with Medicare marketing experience cautioned that seniors are influenced by strong inertial forces that may disappoint those expecting rapid uptake in enrollment, resulting in at least initially low enrollments such as those in the Medicare drug card program.

Geographic adjustment for regional plans. MMA permits the HHS secretary to determine if a geographic adjustor is necessary to encourage plans to participate as regional PPOs. Newly issued regulations from the Centers for Medicare and Medicaid Services (CMS) envision such an adjustor, although its design remains to be detailed.¹⁴ At the time of our interviews, most plans were under the impression that they would receive the same payment rate across an entire region and not have the benefit of within-region payment refinement. A decision to develop a county-level adjustor might well reduce some plans’ concerns about serving a diverse geographic area and increase their likelihood of entry. However, it could also encourage plans to attract beneficiaries who reside in markets where payment rates to plans would be adjusted upward, while discouraging plans from marketing effectively in subregional areas, where payments and profits may be lower. This could undermine one of the principal goals of MMA—getting plans to serve regions previously unserved by private plans—by encouraging plans to engage in selective marketing.

The next sever al months will reveal much about whether Congress’s concerted efforts to create an attractive market for regional PPOs have been successful. The pace of regional MA PPO enrollment will be particularly important because it will have a substantial bearing on providers’ willingness to join networks and grant discounts to make the product financially successful. This in turn will affect plans’ willingness to make further investments to expand enrollment. Early and sustained growth is also important to policymakers, who have staked much on the potential of private plan options and who will face intense criticism if this potential does not pay off. Skeptics already raising questions about sharply increased health plan payments and other financial inducements made to plans despite growing federal deficits are unlikely to show much patience if the privatization strategy falters.

Editor's Notes

 
Robert Hurley (rhurley{at}hsc.vcu.edu) is an associate professor in the Department of Health Administration, Virginia Commonwealth University, in Richmond. Bradley Strunk is a health researcher at the Center for Studying Health System Change (HSC) in Washington, D.C. Joy Grossman is a senior health researcher at HSC.

Data collection and analysis were supported by the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services (HHS); article preparation was supported by the Robert Wood Johnson Foundation. The content of this paper does not necessarily reflect the views or policies of HHS, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. government.

NOTES

Top Findings Issues To Watch NOTES

 

1. Centers for Medicare and Medicaid Services, Establishing Regional Medicare PPOs and PDPs under the Medicare Modernization Act, 9 February 2005, www.cms.hhs.gov/medicarereform/mmaregions (18 April 2005).
2. P. Ginsburg et al., Options for Defining Medicare Advantage Regions: An Assessment of Tradeoffs, Report prepared for the Office of the Assistant Secretary for Planning and Evaluation, DHHS (Washington: Center for Studying Health System Change, 2004).
3. J. O’Sullivan et al., Overview of the Medicare Prescription Drug and Reform Conference Agreement (Washington: Congressional Research Service, December 2003).
4. CMS, "Key Projected Dates in the Implementation of Title I and II," www.cms.hhs.gov/medicarereform/mma-t1t2-calendar.pdf (18 April 2005).
5. B. Biles, G. Dallek, and L.H. Nicholas, "Medicare Advantage: Déjà Vu All Over Again," Health Affairs, 15 December 2004, content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.586 (22 February 2005).
6. R.A. Berenson, "Medicare Disadvantaged and the Search for the Elusive ‘Level Playing Field’," Health Affairs, 15 December 2004, content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.572 (22 February 2005).
7. P. Kemper et al., "The Design of the Community Tracking Study: A Longitudinal Study of Health System Change and Its Effects on People," Inquiry 33, no. 2 (1996): 195–206.[ISI][Medline]
8. R.E. Hurley, J.M. Grossman, and B.C. Strunk, "Medicare Risk Contracting/Medicare Contracting Risk: A Life-Cycle View from Twelve Markets," Health Services Research 38, no. 1, Part 2 (2003): 395–417. The twelve CTS sites are Boston, Cleveland, Greenville, Indianapolis, Lansing, Little Rock, Miami, northern New Jersey, Orange County (California), Phoenix, Seattle, and Syracuse.[CrossRef][ISI][Medline]
9. J. White, R. Hurley, and B. Strunk, "Getting Along or Going Along: Health Plan-Provider Showdowns Subside," Issue Brief no. 74 (Washington: HSC, January 2004).
10. Medicare Payment Advisory Commission, "Market Variation: Implications for Beneficiaries and Policy Report," chap. 2 in Report to Congress (Washington: MedPAC, June 2003), 19–38.
11. O’Sullivan et al., Overview.
12. R. Pear, "Insurers Object to New Provision in Medicare Law," New York Times, 22 August 2004.
13. J.C. Robinson, "For-Profit Non-Conversion and Regulatory Firestorm at CareFirst BlueCross BlueShield," Health Affairs 23, no. 4 (2004): 68–83.[Abstract/Free Full Text]
14. CMS, "Medicare Fact Sheet: Final Rules for Implementing the New Medicare Law," 21 January 2005, www.cms.hhs.gov/medicarereform/pdbma/fs-pdbmafinalrules.pdf (18 April 2005).

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