Managed Competition Brief - Semantic Scholar

Rural Policy Brief Volume Eight, Number 8

(PB2003-8)

Enrollment in FEHBP Plans in Rural America: What Are the Implications for Medicare Reform? Authors: Timothy McBride, Ph.D. Keith Mueller, Ph.D. Courtney Andrews, A.B.D. Liyan Xu, M.S. Roslyn Fraser, B.A.

The Rural Policy Brief series is published by the Rural Policy Research Institute (RUPRI) for the RUPRI Center for Rural Health Policy Analysis. RUPRI provides objective analyses and facilitates dialogue concerning public policy impacts on rural people and places. The RUPRI Center for Rural Health Policy Analysis is one of six Rural Health Research Centers funded (Grant #5U1C RH00025) by the Federal Office of Rural Health Policy. The mission of the Center is to provide timely analysis to federal and state health policymakers, based on the best available research. For more information about the Center and its publications, please contact: RUPRI Center for Rural Health Policy Analysis, 984350 Nebraska Medical Center, Omaha, NE 68198-4350. (402) 559-5260. http://www.rupri.org/healthpolicy

June 2003

RUPRI Center for Rural Health Policy Analysis

Recent proposals to reform the Medicare program and add an outpatient prescription drug benefit have used the Federal Employees Health Benefits Program (FEHBP) as the model for how private plans could be incorporated into the Medicare program. In this Policy Brief, we present information showing how FEHBP is functioning in non-metropolitan (rural) areas of the country. We present enrollment patterns into the various options available in the FEHBP, descriptions of the choices typically available in rural areas, and location of primary care providers used by plans in a sample of rural communities.

What is FEHBP and how does it work? FEHBP is administered by the Office of Personnel Management (OPM), which negotiates with insurance carriers wanting to offer their plan options to federal employees. The In places where the competing availability of choices is health plans are unlikely to ever driven by how many plans emerge, any policy predicated want to be in the market on assumptions that competing under the general plans will deliver health conditions put forth by the insurance benefits needs to OPM. Currently seven have a “fallback” option that is national plans offer 12 guaranteed to work. options, meaning all rural areas have at least that Full Policy Implications on many choices technically Page 12 (back cover) available.1 In many areas, an additional six plans are offered for specific groups (e.g., the Secret Service) that other federal employees can join by paying a fee. Finally, in 2001, over 200 other plans were available in specific regions. All plans in the FEHBP are either health maintenance organizations (HMOs) or preferred provider organizations (PPOs). The PPO plans, which include the 12 nationwide plan options, have higher out-of-pocket costs when using providers who do not participate in the PPO. The fact that plan options are available because they are listed on the OPM web site does not mean they are viable choices for rural residents. We approach the issue of viability by using two different indicators. 1.

Examining choices actually made by federal employees is a more accurate portrayal of viable choices than listing available choices.

2.

The proximity of primary care providers participating in the PPO influences choices. RUPRI Rural Policy Brief Volume 8, Number 8

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Enrollment into FEHBP Choices This Brief focuses on actual enrollment patterns in FEHBP plans, differentiated across rural and urban areas. People are showing us with the choice they made what choices were viable. Table 1 shows that about 3.7 million employees and annuitants were enrolled in FEHBP across the U.S. in 2001 and that there are significant differences in rural and urban patterns: •

Total rural enrollment was just over 592,000; urban enrollment was 3.1 million.

•

Six nationwide plans accounted for 87% of rural enrollment; those same six plans accounted for 67% of urban enrollment.

•

Blue Cross/Blue Shield’s (BC/BS) nationwide plan accounts for 58% of rural enrollment. As evident in the section on Access to Primary Care in FEHBP Choices (below), in many rural communities BC/BS is the only plan using local providers in its PPO.

Retirees (annuitants) are the majority of rural FEHBP enrollees (58%), and these retirees making FEHBP choices could be a close parallel to what would be the experience of Medicare beneficiaries. Table 2 shows that annuitants are more likely than other rural persons to congregate in nationwide plans (90% of rural annuitants enrolled in nationwide plans, as compared to 87% of all rural FEHBP enrollees). While 86% of metropolitan counties had 10 or more plans active with enrollment in 2001, only 30% of rural counties had 10 or more active plans (Table 3). Of course, this is explained by the fact that some rural counties have too few federal employees to expect enrollment in 10 or more plans. However, Table 3 shows that several rural counties had very few FEHBP enrollees (13 rural counties had 1-5 FEHBP enrollees, and 22 counties had 6-9 FEHBP enrollees). For further information see www.rupri.org/healthpolicy. The county-specific data confirm the aggregated data: the vast majority of rural FEHBP enrollees congregate into just a few plans, primarily into the nationwide plans, and into the BC/BS plan in particular.

Access to Primary Care in FEHBP Choices Differences in out-of-pocket costs between using in-network providers vs. out-of-network providers can be substantial (Table 4). Most persons would presumably prefer to see a physician who participates in the PPO they would choose. In rural areas this would typically mean that the preference is for the local primary care provider to be a PPO provider, making proximity a selection criteria that may restrict choice in many rural communities. Table 5 shows the proximity of the nearest primary care providers in each of the plan options available to rural residents, in communities of various size.2 In rural areas, enrollees in some FEHBP plans have access to providers in closer proximity to their residence. For example, enrollees in the BCBS plan in Lolita, Texas, have four primary care providers within 10 miles of their residence, and enrollees in the BCBS plan in Mullen, Nebraska, have two primary care providers within the same community; enrollees in other plans would travel at least 20 miles (from Lolita) and 100 miles (from Mullen) to the nearest primary care provider. Persons in small rural communities face restricted choices if they want the economic advantage of PPOs and the convenience of using their local primary care physician. Only the BC/BS plans consistently include the nearest physicians in their PPOs (they also include the more distant physicians; the table reports only the number in the nearest location).

2

RUPRI Rural Policy Brief Volume 8, Number 8


3

Plan Name

4.0% 11.2%

Other Plans with significant enrollment in rural areas (with more than 1000 rural enrollees): 38 National Rural Letter Carriers Association Total in all other plans

4.4% 5.6%

4.2% 8.6%

58.4% 14.2% 8.6% 2.7% 2.6% 0.6% 0.1% 87.2%

0.5% 32.8%

47.4% 9.3% 5.3% 1.9% 2.5% 0.2% 0.1% 66.7%

1.1% 29.0%

49.2% 10.1% 5.8% 2.0% 2.5% 0.3% 0.1% 69.9%

100.0%

(Percentage of FEHB enrollees) 100.0% 100.0% 100.0% 59.0% 15.1% 9.9% 2.8% 2.5% 0.7% 0.1% 90.1%

40,792 1,082,317

24,704 51,116

16,088 1,031,201

11,793 14,954

SOURCE: Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis, based on data from U.S. Office of Personnel Management. NOTE: Enrollment does not include dependents.

57.9% 13.5% 7.5% 2.5% 2.7% 0.6% 0.1% 84.8%

100.0%

12,911 36,162

1,835,891 375,207 215,835 76,479 92,403 10,253 3,930 2,609,998

158,663 40,518 26,621 7,627 6,619 1,958 308 242,314

187,214 43,557 24,303 8,117 8,681 1,816 367 274,055

1,490,014 291,132 164,911 60,735 77,103 6,479 3,255 2,093,629

3,733,107

(Number of FEHB enrollees) 269,061 592,189 3,140,918

323,128 345,877 84,075 50,924 15,744 15,300 3,774 675 516,369

Total

Rural total

Urban

Rural Rural Adjacent Nonadjacent

TOTAL ENROLLEES IN FEHBP PLANS Nationwide plans: 10 Blue Cross and Blue Shield Plan 45 Mail Handlers Benefit Plan 31 GEHA (Government Employees Hospital Association) Benefit Plan 47 APWU (American Postal Workers Union) Health Plan 32 NALC (National Association of Letter Carriers) 36 PBP (Postmasters Benefits Plan) (National League of Postmasters) 1R Alliance Health Plan Total in these nationwide plans

Other Plans with significant enrollment in rural areas (with more than 10,000 rural enrollees): 38 National Rural Letter Carriers Association Total in all other plans

TOTAL ENROLLEES IN FEHBP PLANS Nationwide plans: 10 Blue Cross and Blue Shield Plan 45 Mail Handlers Plan 31 GEHA (Government Employees Hospital Association) Benefit Plan 47 APWU (American Postal Workers Union) Health Plan 32 NALC (National Association of Letter Carriers) 36 PBP (Postmasters Benefits Plan) (National League of Postmasters) 1R Alliance Health Plan Total in these nationwide plans

Plan No.

Table 1. Enrollment in Federal Employees Health Benefits Program Plans, by Resident Location of Enrollee, 2001

Table 2. Enrollment in Federal Employees Health Benefits Program Plans, by Type of Enrollee and Residence, 2001 All enrollees

Rural total

Rural Rural adjacent nonadjacent

All Enrollees, by Type & Location Nationwide plans Other plans

100.0% 69.9% 30.1%

100.0% 87.2% 12.8%

100.0% 84.8% 15.2%

100.0% 90.1% 9.9%

100.0% 66.7% 33.3%

100.0% 59.7% 40.3%

100.0% 76.7% 23.3%

Annuitants (Retirees) Nationwide plans Other plans

100.0% 81.2% 18.8%

100.0% 89.3% 10.7%

100.0% 88.5% 11.5%

100.0% 90.3% 9.7%

100.0% 79.2% 20.8%

100.0% 74.6% 25.4%

100.0% 84.5% 15.5%

Non-Postal workers Nationwide plans Other plans

100.0% 62.4% 37.6%

100.0% 86.4% 13.6%

100.0% 80.4% 19.6%

100.0% 92.4% 7.6%

100.0% 58.9% 41.1%

100.0% 52.4% 47.6%

100.0% 69.9% 30.1%

Postal workers Nationwide plans Other plans

100.0% 55.1% 44.9%

100.0% 80.2% 19.8%

100.0% 75.9% 24.1%

100.0% 84.7% 15.3%

100.0% 51.5% 48.5%

100.0% 43.8% 56.2%

100.0% 65.6% 34.4%

Urban total Central urban Other urban

SOURCE: Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis, based on data from U.S. Office of Personnel Management. NOTE: Enrollment does not include dependents.

Table 3.

Federal Employees Health Benefits Program Plan Activity by County, 2001

Rural Metropolitan All Counties Counties Counties No plans 0% 0% 0% 1-2 plans 2% 2% 2% 3-5 plans 11% 2% 8% 6-9 plans 57% 12% 45% 10 or more plans 30% 86% 45% Source: Office of Personnel Management, Office of Actuarial Data, based on enrollment by federal employees.

4


Table 4. Nationwide Health Plans: Out-of-Pocket Costs Alliance Health Plan

Deductible $200

Deductible $400

Inpatient PPO Copay $150 per admission NonPPO Copay None

Coinsurance 10%

Physician Visits PPO Deductible Copay (per visit) $200 $15

Coinsurance 10%

Coinsurance 30%

NonPPO Deductible Copay (per visit) $500 None

Coinsurance 50%

Coinsurance 15% 10%

Coinsurance 40% 30%

APWU Health Plan

Plan Type Low High

Deductible None None

Inpatient PPO Copay None None

Plan Type Low High

Deductible None $200

NonPPO Copay None None

Coinsurance 15% 10%

Physician Visits PPO Deductible Copay (per visit) None None $250 $15

Coinsurance 40% 30%

NonPPO Deductible Copay (per visit) None None $350 None

Blue Cross and Blue Shield Service Benefit Plan

Plan Type Standard Basic

Deductible $250 None

Inpatient PPO Copay None $100 per day*5

Plan Type Standard Basic

Deductible $250 n/a

NonPPO Copay None n/a

Coinsurance 10% None

Physician Visits PPO Deductible Copay (per visit) None $15 None $20-30

Coinsurance 25% n/a

NonPPO Deductible Copay (per visit) $250 None No NonPPO Benefits

Coinsurance None None

Coinsurance 25%

GEHA Benefit Plan

Plan Type Standard High

Deductible $450 $100 per admission






Physician Visits PPO Deductible Copay (per visit) $450 None $350 None

Coinsurance 15% 10%


NonPPO Deductible Copay (per visit) $450 None $350 None

Coinsurance 35% 25%


5

Table 4. (continued) Nationwide Health Plans: Out-of-Pocket Costs Mail Handlers

Plan Type Standard

Deductible None

High

None

Inpatient PPO Copay $150 per admission None

Plan Type Standard

Deductible None

NonPPO Copay None

High

None

None

Coinsurance None None

Coinsurance $300 per admission $250 per admission

Physician Visits PPO Deductible Copay (per visit) None $18 None

Coinsurance None

$15

None

NonPPO Deductible Copay (per visit) None None

Coinsurance 30%

None

None

30%

Coinsurance 10%

Physician Visits PPO Deductible Copay (per visit) None $20

Coinsurance 15%

Coinsurance 30%

NonPPO Deductible Copay (per visit) None None

Coinsurance 30%

Coinsurance None 10%

Coinsurance 30% 25%

NALC Health Plan

Deductible None

Deductible None

Inpatient PPO Copay None NonPPO Copay $100 per admission

PBP Health Plan


Deductible None None




Coinsurance 9% 10%

Physician Visits PPO Deductible Copay (per visit) None $8 None None


Coinsurance 30% 25%

NonPPO Deductible Copay (per visit) None None None None

Sources: Office of Personnel Management: http://www.opm.gov; Alliance Health Plan: http://www.geoaccess.com/phcs/po/; APWU Health Plan: http://www.apwuhp.com/; Blue Cross and Blue Shield Service Plan: http://www.fepblue.org/; GEHA Benefit Plan: http://www.geha.com/; Mail Handlers: http://www.firsthealth.com/ghp/servlet/GHPServlet; NALC: http://www.nalc.org/depart/hbp/Providers/FH/index.html; PBP Health Plan: http://www.postmasters.org/pbp.asp; WINhealth: www.winhealthpartners.org; Healthnet AZ: www.az.health.net; BlueChoice: www.bcbsmo.com; Coventry: www.chckansas.com; Mercy: www.mercyhealthplans.com

6



7

Glendive, Miles City, MT Glendive, Miles City, MT Glendive, Miles City, MT Miles City, MT

GEHA

Population: 700

70

60 5

4

4

7

1

PBP

Port Lavaca, Edna, TX

25

20

NALC 16

18

23

20

Port Lavaca, TX

15

20

Placios, Port Lavaca, TX Mail Handlers Port Lavaca, TX

GEHA

BCBS

APWU

Plan Alliance

Lolita, TX

PBP

NALC

60

60

20

100

50

50

20

50

1

1

1

1

1

19

22

35

24

20

20

20

20

2

3

3

2

2

2

Hospitals Within Nearest Distance 2

Providers Accepting Medicare: 0

8

7

9

18

3

Hospitals Within Nearest Distance 0 1


Nationwide Fee-For-Service (PPO) Plans and Location of Providers Primary Distance to Care Total Nearest Location of Primary Providers Providers Distance to Care Within Within Nearest Nearest Providers Nearest Nearest Hospitals Primary Care (miles) Distance Distance (miles) Providers Placios, Port 20 15 32 20 Lavaca, TX Placios, Port 20 13 18 20 Lavaca, TX Edna, TX 10 4 9 20

Baker, MT

Mail Handlers

Population: 140

Nationwide Fee-For-Service (PPO) Plans and Location of Providers Primary Distance to Total Care Nearest Location of Primary Providers Providers Distance to Nearest Within Within Nearest Care Hospitals Nearest Nearest Primary Care Providers (miles) (miles) Distance Distance Providers Miles City, MT 70 5 8 100 Miles City, MT 70 4 11 20

BCBS

Plan Alliance APWU

Plevna, MT

Table 5. Availability of PPO Providers in Selected Communities

WINhealth

PBP

NALC

Population: 768

100

100

100

100

0

16

16

32

50

80

80

100

Spearfish, Sturgis, SD Spearfish, Deadwood, SD Spearfish, Sturgis, SD Hill City, SD

100

70

60

100

0

12

7

22

1

1

1

4

1

24

19

47

25

30

30

50

na

1

1

1

1

2

1



0

23

24

49

Nationwide Fee-For-Service (PPO) Plans and Location of Providers Distance to Primary Total Nearest Care Location of Primary Providers Providers Distance to Within Within Nearest Nearest Care Providers Nearest Nearest Hospitals Primary Care Distance Distance (miles) Providers (miles) Buffalo, WY; 100 0 3 100 Custer, SD Spearfish, 70 7 17 40 Deadwood, SD Moorcroft, WY 0 1 2 40

N. Platte, Valentine, NE N. Platte, Valentine, N. Platte, Valentine, Mullen, NE

2

Hospitals Within Nearest Distance 1 1


Population Category: 0-9999

Local and Regional Fee-For-Service (PPO) Plans and Location of Providers n/a n/a 0 0 na

Mail Handlers

GEHA

BCBS

APWU

Plan Alliance

Population: 554

Nationwide Fee-For-Service (PPO) Plans and Location of Providers Primary Distance to Care Total Nearest Location of Primary Providers Providers Distance to Nearest Nearest Care Within Within Hospitals Primary Care Providers Nearest Nearest (miles) Providers (miles) Distance Distance Big Springs, NE 100 1 2 90 100 13 18 80 Alliance, Broken Bow, Sargent, Mullen, NE 0 2 2 60

Moorcroft, WY

PBP

NALC

Mail Handlers

GEHA

BCBS

Plan Alliance APWU

Mullen, NE

8


San Manuel, Kearney, AZ Globe, AZ

Mail Handlers 30

20

20

8

3

1

20

5

1

30

30

50

Boulder, Helena, MT Boulder, Helena, MT Deer Lodge, Butte, MT

Mail Handlers

PBP

NALC

Helena, MT

GEHA

BCBS

APWU

Plan Alliance

Population: 1,635

100

40

40

50

7

34

34

9

28

43

54

13

10

30

30

0

1

1

1

1

1

1



Nationwide Fee-For-Service (PPO) Plans and Location of Providers Primary Distance to Nearest Care Total Primary Providers Providers Distance to Location of Care Within Within Nearest Nearest Providers Nearest Nearest Hospitals Primary Care (miles) Providers (miles) Distance Distance Livingston, 80 1 4 100 Anaconda, MT Boulder, 40 27 44 0 Helena, MT Boulder, MT 30 4 19 0

Townsend, MT

n/a

2

1

1

3

2

1



San Manuel, 25 2 2 50 Kearney, AZ Local and Regional Fee-For-Service (PPO) Plans and Location of Providers HealthNet AZ Superior, AZ 25 1 7 na

PBP

NALC

Kearney, AZ

GEHA

BCBS

APWU

Plan Alliance

Population: 1,356

Nationwide Fee-For-Service (PPO) Plans and Location of Providers Primary Distance to Total Care Nearest Location of Primary Providers Providers Distance to Nearest Care Within Within Nearest Nearest Hospitals Providers Nearest Primary Care Distance (miles) (miles) Distance Providers Hayden, 20 1 3 40 Kearney, AZ Globe, 40 5 37 40 Claypool, San Manuel, AZ 20 2 4 40

Dudleyville, AZ

Fullerton, NE

O'Neil, Niobrara, NE

PBP

NALC

Mail Handlers

GEHA

BCBS

APWU

Plan Alliance

Population: 1,872

100

20

20

50

0

3

3

3

47

7

50

20

20

50

20

Calhoun City, MS

Water Valley, MS Calhoun City, MS Calhoun City, MS Bruce, Woodland, MS Houston, MS

0

20

20

10

0

10

2

4

5

5

2

1

1

1

1

5

2

8

5

5

5

3

1

0

30

50

10

10

10

1

1

3

1

1

1



21

5

4

165

9

2



Nationwide Fee-For-Service (PPO) Plans and Location of Providers Primary Distance to Nearest Care Total Primary Providers Providers Distance to Location of Care Within Within Nearest Nearest Providers Nearest Nearest Hospitals Primary Care (miles) Providers (miles) Distance Distance Bruce, MS 20 1 1 60

Calhoun City, MS

PBP

St. Paul, Central City, Genoa, Mail Handlers St. Paul, Genoa, NE NALC St. Paul, NE

GEHA

BCBS

APWU

Plan Alliance

Population: 1,452

Population Category: 1,000-3,499 Nationwide Fee-For-Service (PPO) Plans and Location of Providers Primary Distance to Care Total Nearest Primary Providers Providers Distance to Location of Within Within Nearest Care Nearest Nearest Nearest Hospitals Primary Care Providers (miles) Distance Distance Providers (miles) Grand Island, 40 1 28 40 NE St. Paul, NE 30 4 6 30

Fullerton, NE

Table 5. (continued) Availability of PPO Providers in Selected Communities


9

Columbus, Billings, MT Lewiston, MT

Mail Handlers

Arab, AL

Arab, AL

Arab, AL

Arab, AL

BCBS

GEHA

Mail Handlers

NALC

Albertville, Guntersville, AL

Arab, AL

PBP

Population: 7,174

100

0

100

0

0

50

1

20

1

12

50

50

50

0

0

25

0

0

0

0

0

5

1

1

6

7

1

1

1

1

1

1

8

2

4

7

22

4

25

20

10

10

10

30

1

2

1

1

1

3



106

1

32

1

33

1



Nationwide Fee-For-Service (PPO) Plans and Location of Providers Distance to Primary Nearest Care Total Location of Primary Providers Providers Distance to Nearest Care Within Within Nearest Primary Care Providers Nearest Nearest Hospitals Providers (miles) Distance Distance (miles) Arab, AL 0 4 9 10

APWU

Plan Alliance

Arab, AL

PBP

Billings, MT

Lewiston, MT

GEHA

NALC

Lewiston, MT

BCBS

APWU

Plan Alliance

Population: 5,813

Nationwide Fee-For-Service (PPO) Plans and Location of Providers Primary Distance to Care Total Nearest Primary Providers Providers Distance to Location of Within Within Nearest Care Nearest Nearest Nearest Hospitals Providers Primary Care Distance Distance (miles) (miles) Providers none within 100 100 0 0 100 miles Lewiston, MT 0 1 1 0

Lewiston, MT

PBP

NALC

Mail Handlers

GEHA

BCBS

APWU

Plan Alliance

McCook, NE

PBP

NALC

Mail Handlers

GEHA

BCBS

APWU

Plan Alliance

Population: 7,994

100

50

0

0

10

0

2

12

1

1

28

12

50

50

50

20

10

20

Colby, KS

Bird City, KS

Bird City, KS

McCook, NE

McCook, NE

Colby, KS

100

50

50

0

0

70

6

1

1

1

10

1

1

2

2

1

1

1

10

2

4

9

48

3

25

60

60

40

0

70

1

1

1

1

1

1



4

50

3

1

94

44

Nationwide Fee-For-Service (PPO) Plans and Location of Providers Distance to Primary Nearest Care Total Primary Providers Providers Distance to Location of Nearest Care Within Within Nearest Primary Care Providers Nearest Nearest Hospitals Providers (miles) Distance Distance (miles) Oberlin, KS 40 3 11 60

Camden, ME

Bangor, ME

Ellsworth, ME

York, ME; Moody, ME Ellsworth, ME

Ellsworth, ME



Population Category: 3,500-9,999 Population: 6,456

Nationwide Fee-For-Service (PPO) Plans and Location of Providers Primary Distance to Care Total Nearest Primary Providers Providers Distance to Location of Within Within Nearest Care Nearest Nearest Nearest Hospitals Providers Primary Care Distance Distance (miles) (miles) Providers Ellsworth, ME 0 1 2 20

Ellsworth, ME


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RUPRI Rural Policy Brief Volume 8, Number 8 9

24

30 0

0

0

1

1

1

1

40

0

1 13 23 1 3 0

0 0 100 0 0 100

1

1

4

3

39

>100

2

100

80

80

100

0

80

1

1

1

2

1

1



24

n/a

PBP

NALC

Mail Handlers

GEHA

BCBS

APWU

Plan Alliance

Population: 12,911

Population: 24,064

10

0

0

0

0

0

27

2

2

3

31

2

50

0

0

0

0

30

Belleville, KS; Beloit, KS

Hastings, NE

Hastings, NE

Hastings, NE

Hastings, NE

100

0

0

0

0

2

1

2

1

35

8

1

1

1

1

2

15

4

8

7

>100

50

30

30

50

0

3

3

3

4

1

1



60

5

5

5

54

5

Nationwide Fee-For-Service (PPO) Plans and Location of Providers Distance to Primary Care Total Nearest Location of Primary Providers Providers Distance to Nearest Within Within Nearest Care Hospitals Primary Care Providers Nearest Nearest (miles) (miles) Distance Distance Providers Grand Island, 30 1 22 30 NE Hastings, NE 0 1 7 30

Jackson, MS

Canton, MS

Canton, MS

Canton, MS

Canton, MS

Canton, MS



Nationwide Fee-For-Service (PPO) Plans and Location of Providers Primary Distance to Care Total Nearest Primary Providers Providers Distance to Location of Nearest Within Within Care Nearest Hospitals Nearest Nearest Providers Primary Care (miles) Distance Distance (miles) Providers Canton, MS 0 2 4 50

Hastings, NE

PBP

NALC

Mail Handlers

GEHA

BCBS

APWU

Plan Alliance

Canton, MS

Population Category: 10,000-49,000

Sources: Office of Personnel Management: http://www.opm.gov; Alliance Health Plan: http://www.geoaccess.com/phcs/po/; APWU Health Plan: http://www.apwuhp.com/; Blue Cross and Blue Shield Service Plan: http://www.fepblue.org/; GEHA Benefit Plan: http://www.geha.com/; Mail Handlers: http://www.firsthealth.com/ghp/servlet/GHPServlet; NALC: http://www.nalc.org/depart/hbp/Providers/FH/index.html; PBP Health Plan: http://www.postmasters.org/pbp.asp; WINhealth: www.winhealthpartners.org; Healthnet AZ: www.az.health.net; BlueChoice: www.bcbsmo.com; Coventry: www.chckansas.com; Mercy: www.mercyhealthplans.com

Rock Springs, WY BCBS Rock Springs, WY GEHA Kemmerer, WY; Cokeville, WY Mail Handlers Rock Springs, WY NALC Rock Springs, WY PBP Rock Springs, WY

APWU

Plan Alliance

Population: 18,708

7

6

Nationwide Fee-For-Service (PPO) Plans and Location of Providers Distance to Primary Nearest Care Total Location of Primary Providers Providers Distance to Nearest Nearest Care Within Within Hospitals Nearest Nearest Primary Care Providers (miles) Providers (miles) Distance Distance Lyman, WY 70 1 6 80

Rock Springs, WY

0

0

Carthage

0

10

31

0

1

Mercy

Carthage

PBP

0

10

22

0

1

1

Carthage

NALC

0

9

36

0

Carthage

Carthage

Mail Handlers

0

9

28

Coventry

Carthage

GEHA

0

11

1

Carthage

BCBS

0



Local and Regional Fee-For-Service (PPO) Plans and Location of Providers Blue Choice Carthage 0 7 24 0

Carthage

APWU

Plan Alliance

Population: 12,668

Nationwide Fee-For-Service (PPO) Plans and Location of Providers Primary Distance to Care Total Nearest Primary Providers Providers Distance to Location of Nearest Within Within Care Nearest Hospitals Nearest Nearest Providers Primary Care (miles) Distance Distance (miles) Providers Carthage 0 14 32 0

Carthage, MO


Glossary and Notes Nationwide Plans: Alliance APWU BCBS GEHA Mail Handlers NALC PBP

Alliance Health Plan American Postal Workers Union Health Plan Blue Cross and Blue Shield Service Benefit Plat Government Employees Hospital Association Benefit Plan Mail Handlers Benefit Plan National Association of Letter Carriers Health Benefit Plan Postmasters Benefits Plan

Local Plans: BlueCHOICE WINhealth HealthNet AZ Coventry Mercy (MO)

Blue Cross Blue Shield of Missouri BlueCHOICE Benefit Plan WINhealth Partners (WY) Health Net of Arizona Coventry Health Care of Kansas Mercy Health Plans

Notes to Table 4: Copay (Co-payment): A fixed amount that the beneficiary pays to the provider, facility, or pharmacy when receiving services. Deductible: A fixed amount of covered expenses that the beneficiary must incur for certain covered services and supplies before the plan starts paying benefits. Co-payments do not count toward any deductible. Coinsurance: The percentage of the plan’s allowance that the beneficiary must pay for care. Coinsurance does not begin until the beneficiary meets the deductible. Notes to Table 5: Plan: Type of Federal Employees Health Benefits Program plan Location of Nearest Primary Care Providers: Nearest location from the selected community where enrollee could see a primary care provider Distance to Nearest Primary Care Providers: Distance from the selected community to the nearest primary care provider, as stated by the plan Primary Care Providers Within Nearest Distance: Number of primary care providers (including family practice, general practice, internal medicine, obstetrics & gynecology and pediatrics) who are within the Total Providers: Number of all health care providers (including primary care providers) who are within the Distance to Nearest Hospitals: Distance from the selected community to the nearest hospital Hospitals Within Nearest Distance: Number of hospitals that are within the Distance to Nearest Hospitals Methodology: Data on location of and distance to primary care providers was collected from the web sites for each of the plans. The Office of Personnel Management’s web site (www.opm.gov) was used to learn which plans are available in each of the selected communities. Location and distance were obtained by conducting a search using the provider search engines on each of the plans’ web sites. Provider search engines are available online for enrollees in health care plans so that they can locate primary care physicians and other providers in their network.


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Policy Implications While the FEHBP experience can inform discussions of Medicare policies, the comparison is not perfect. FEHBP enrollees may have favorable health status compared to the general population, both active workers and retirees (because federal workers are likely to be more educated and have higher incomes than the general population). Therefore, we can expect that the average health care costs of the FEHBP population will be lower (and less volatile) than the typical Medicare population. This comparison of populations could predict less desire to offer plans to Medicare beneficiaries than to federal employees, especially in rural areas. Conversely, to participate in the FEHBP, plans must offer open enrollment and accept the oversight of the OPM, including offering required benefits. Medicare policies might be different and conceivably more attractive. Prospects for attracting competing plans to offer drug benefits only may create unique markets. The FEHBP is a government-sponsored system that makes multiple choices available everywhere in the U.S., but not necessarily viable. Therefore, any major revisions in Medicare that would require enrollment in competing plans to be successful would not succeed in all rural counties unless there were departures from the “pure” FEHBP model. Examples of such policy by exception exist in the two Medicare bills passed in the Senate and House in June 2003: •

The Senate bill would have the Secretary of HHS contract directly with a single health plan to provide prescription drug coverage in those places without voluntary entry by competing plans.

•

The House bill would allow the Administrator to subsidize the risk associated with offering the prescription drug benefit until at least two plans would enter every market.

In addition to these “fallback” options, policies relying on competing plans need to consider another reality of the FEHBP experience in rural areas—the use of provider panels that do not include local primary care providers. The 2003 Medicare bills implicitly acknowledge this concern with these provisions: •

Both bills have provisions requiring that plans include pharmacies (excluding mail order) that are convenient to the beneficiary, with convenience defined in regulation.

•

The Senate bill has a requirement that plans include a point-of-service option that allows beneficiaries to use any pharmacy, perhaps paying more out-of-pocket for those services.

•

The House bill has an “any willing provider” provision requiring that plans accept any pharmacy into their panel that is willing to accept the plan’s terms.

The various provisions in the 2003 Medicare bills are an effort to overcome inherent problems with the “competitive model” in extending a prescription drug benefit to rural areas. Similar considerations would be needed in any broader application of the model to the balance of Medicare benefits. There are rural places in the U.S. where efforts to encourage a competitive marketplace in health insurance have not been successful, including FEHBP, Medicare+Choice, and commercial insurance. In places where the competing health plans are unlikely to ever emerge, any policy predicated on assumptions that competing plans will deliver health insurance benefits needs to have a “fallback” option that is guaranteed to work. 1

For detailed information on the FEHBP, consult the OPM’s web site at: http://www.opm.gov/insure/health/. In addition, detailed information on the FEHBP can be found in the following publication: “The 2001 Guide to the Federal Employees Health Benefits Plans for Federal Civilian Employees,” U.S. Office of Personnel Management, November 2000, RI 70-1, Washington, DC: GPO. 2

We selected communities from states that were used in a previous RUPRI Center publication, Health Services at Risk in “Vulnerable” Rural Places (PB2002-5), available at www.rupri.org/healthpolicy. Anyone wishing to replicate this work for a different community can do so using the OPM and plan websites, per the methodology described in the Notes to Table 5. 12
