Medicare+Choice Withdrawals: Experiences in Major Metropolitan ...

Insights

MONITORING +

MEDICARE CHOICE

OPERATIONAL September 2002, Number 8

Medicare+Choice Withdrawals: Experiences in Major Metropolitan Areas ithdrawals by Medicare+Choice plans affected about 2.2 million Medicare beneficiaries between 1999 and 2002 (Gold and McCoy, 2002). This number will likely grow in 2003 as plans notify the Centers for Medicare and Medicaid Services (CMS) this September in which counties they expect to offer or stop offering

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While 1.3 million enrollees in the nation’s 66 largest urban markets were affected by withdrawals, these markets fared proportionately better than the rest of the country. products during the coming year. Many policymakers are concerned about how these withdrawals will affect individual beneficiaries and how to respond, particularly since withdrawals historically are concentrated in markets that have been most unstable. This Operational Insights discusses Medicare+Choice withdrawals across the country, focusing on the experience of 66 large Metropolitan Statistical Areas (MSAs).

by Marsha Gold and John McCoy

these markets as a whole fared proportionately better than the rest of the county. The 66 markets cover more than three-quarters of Medicare+Choice enrollment, but they accounted for only 59 percent of enrollees affected by plan withdrawals. The rest were from other urban (34 percent) and rural (8 percent) areas.

Sixty-Six Markets in National Context Medicare+Choice enrollment was heavily concentrated in major metropolitan areas in 1999 and grew even more so by 2002 (see Figure 1). The 66 large markets studied by MPR accounted for 76 percent of Medicare+Choice enrollees in 1999 and 79 percent in 2002, even though only 43 percent of Medicare beneficiaries lived there. Most of the remaining Medicare+Choice enrollment was and remains concentrated in other urban areas. Twenty-four percent of beneficiaries live in rural areas, but they account for a very small share of Medicare+Choice enrollment. While the number of enrollees affected by plan withdrawals in the 66 markets is very large (1.3 million enrollees, cumulatively),

Hardest Hit Large Markets Of the 66 markets, three lost all of their Medicare+Choice managed care options between 1999 and 2002. Norfolk, VA, lost its sole Medicare+Choice contract in 2000; Medford, OR, went from two contracts to none by 2001; and Spokane, WA, which had five contracts in 1998, lost its last plan in 2002. Even in markets where

Figure 1

Distribution of Medicare Beneficiaries by Type and Geographic Area Percent of National Total 76

80

■ Medicare beneficiaries, 1999 and 2002

79

■ Medicare+Choice enrollees, 1999

70

■ Medicare+Choice enrollees, 2002

59 60 50

■ Cumulative enrollees dropped, 1999-2002 43

40

34

33

30

21

20

24 18 8

10 0

3 66 Markets

All Other (Urban/Suburban)

2

All Other (Rural)

The Monitoring Medicare+Choice Project of Mathematica Policy Research, Inc., seeks to provide credible and timely information on insurance decisions made by Medicare beneficiaries. It is funded by The Robert Wood Johnson Foundation. The database and methods used in this analysis were supported in part through a separate project for the Centers for Medicare and Medicaid Services.

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Top 10 Markets, Net Loss of Medicare+Choice Contracts Number of Contracts 1999

1. Dallas, TX 2. Nassau/Suffolk, NY 3. New Haven, CT 4. Fort Worth, TX 5. Houston, TX 6. Newark, NJ 7. Seattle, WA 8. Tucson, AZ 9. Bakersfield, CA 10.Baton Rouge, LA

8 9 8 7 8 8 7 7 8 5

Net Loss

2002

1 3 2 2 3 3 2 2 4 1

-7 -6 -6 -5 -5 -5 -5 -5 -4 -4

SOURCE: MPR analysis of CMS data

Medicare+Choice plans remain, few are sometimes really available to beneficiaries. For example, Baltimore had two plans remaining by 2002, but one (KaiserPermanente) caps its total enrollment at a relatively low level, and the other (Elder Health) is designed for a specialized group of nursing home residents and Medicare beneficiaries who are dually eligible for Medicaid (MDHMH, 2001). Table 1 shows the top 10 markets that experienced the largest net loss of Medicare+Choice contracts, a loss ranging from four to seven plans each. Reduced competition is not necessarily bad if it means that the remaining plans’ enrollment levels make them more viable. However, in the 10 markets with the largest net loss of plans, two (Dallas and Baton Rouge) were left with only one remaining plan, and four additional markets had only two competitors. Almost half of the Medicare+Choice enrollees affected by withdrawals in the 66 largest markets between 1999 and 2002 lived in 10 markets (see Table 2). These markets are concentrated in the Northeast (around New York City and in Philadelphia and Baltimore) but also include Texas (Houston and Dallas), the Midwest (Chicago and Cleveland), and Florida (Tampa). Each of

these markets had withdrawals that affected between 37,000 and 88,000 enrollees. Together, these 10 markets accounted for 606,623 of the enrollees dropped from the Medicare+Choice program over the period (or 48 percent of those in the 66 markets and 28 percent of the nation’s total). This concentration reflects the uneven distribution of Medicare beneficiaries across the country and the fact that the markets as a whole have been affected disproportionately by withdrawals. The implications of the withdrawals differ across the top 10 MSAs. For example, with more than 1.2 million beneficiaries living in its five boroughs, New York makes the list largely because of its size. Though the number of plans declined from 12 to nine between 1999 and 2002, New York still has as many or more choices than anywhere else except Miami, which has 10 plans. Medicare+Choice penetration in New York, which has always been relatively low, remained steady across the period (at about 18 percent). In contrast, nearby Nassau and Suffolk counties on Long Island saw their penetration drop from 22 percent in 1999 to 14 percent in 2002 as the number of con-

Table 3

Top 10 Markets, Absolute Decline in Medicare+Choice Market Penetration Medicare+Choice Market Penetration Rate 1999

1. Williamsport, PA 2. State College, PA 3. Spokane, WA 4. Houma, LA 5. Baton Rouge, LA 6. Medford, OR 7. Jacksonville, FL 8. Houston, TX 9. Pueblo, CO 10.Fort Worth, TX

35% 38 25 27 34 17 31 25 34 32

Net Change

2002

4% 11 0 7 15 0 15 10 19 18

-31% -28 -25 -20 -18 -17 -16 -14 -14 -14


tracts went from nine to three. New Haven’s experience was similar to that of Nassau and Suffolk counties, which is not surprising because the same plans dominated both markets in 1999. Table 3 shows the 10 markets with the largest net decline in managed care penetration between 1999 and 2002. They include two markets each in Pennsylvania, Louisiana, and Texas, and one each in Washington, Oregon, Florida, and Colorado.

Factors Affecting Withdrawal Table 2

Top 10 Markets, Enrollees Affected by Plan Pullouts Cumulative Number Percent of of Enrollees National Total Affected, Enrollees 1999-2002 Affected

1. Nassau/Suffolk, NY 2. Houston, TX 3. Chicago, IL 4. Dallas, TX 5. Baltimore, MD 6. Philadelphia, PA 7. New Haven, CT 8. Tampa, FL 9. Cleveland, OH 10.New York, NY

87,698 84,886 70,546 68,534 64,713 61,570 49,382 41,212 40,881 37,201

4.1% 4.0 3.3 3.2 3.0 2.9 2.3 1.9 1.9 1.7

Total

606,623

28.4


Recent withdrawals have been influenced by minimal Medicare capitation payment increases—only about 2 percent in most years—and by market-specific conditions. These include local market history with managed care, practice patterns and beneficiary expectations in each market, beneficiary characteristics and coverage, the extent and form of provider organization, trends in other lines of business, state regulation, and geographic proximity to other markets (Brown and Gold, 1999; Young, 2001). Managed care experience may differ substantially even when markets are geographically close, as in Tucson and Phoenix, and Miami and Tampa. In a number of markets, a combination of the underwriting cycle and reduced provider

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willingness to participate in managed care has challenged plans’ ability to retain their provider networks, making it harder for them to remain in the program (Grossman, Strunk, and Hurley, 2002). Small payment increases to plans also limit their ability to negotiate with providers. Provider pressures and the way they are manifested also vary across markets. For example, Maryland state officials were told by plans that their financial efficiency was reduced by the absence of large, vertically integrated provider systems and by providers’ unwillingness to create the data systems and care management infrastructure needed to manage risk. Both factors contributed to decisions to withdraw from the Medicare+Choice program (MDHMH, 2001). Plans in Houston also reported experiencing extensive provider resistance to HMO contracting terms (Stuber, Dallek, and Biles, 2001). Another example of provider-related pressures on plans includes two major hospital systems that decided to limit Medicare+Choice contracting in Cleveland (Dallek and Dennington, 2002). The local effects of withdrawals also reflect plans’ broader corporate strategic decisions. Eight national firms (including the 43 independently and locally owned plans affiliated with Blue Cross-Blue Shield) account for about 70 percent of national enrollment (Draper, Gold, and McCoy, 2002). Five of these eight reduced their Medicare+Choice exposure dramatically between 1999 and 2001. The impact of withdrawals on local markets reflects, to an extent, the role of these firms in each market. For example, Aetna cut its Medicare+Choice enrollment almost in half between 1999 and 2001, concentrating its business in five states. In doing so, it withdrew completely from Ohio and Texas in 2001 (the Texas withdrawal started in 2000 and was substantially completed then). Both states had accounted for substantial enrollment for Aetna.

Table 4

Enrollment and Plan Withdrawal Trends in 66 Markets1 MEDICARE+CHOICE ENROLLEES 2

MEDICARE BENEFICIARIES March 2002 Total for the 66 markets All other areas Urban/suburban Rural National total Albuquerque, NM Atlanta, GA Bakersfield, CA Baltimore, MD Baton Rouge, LA Boston, MA Boulder, CO Chicago, IL Cincinnati, OH Cleveland, OH Colorado Springs, CO Dallas, TX Daytona Beach, FL Denver, CO Detroit, MI Eugene, OR Fort Worth, TX Ft. Lauderdale, FL Honolulu, HI Houma, LA Houston, TX Jacksonville, FL Kansas City, KS-MO Las Vegas, NV Los Angeles, CA Medford, OR Miami, FL Minneapolis, MN Modesto, CA Nassau/Suffolk, NY New Haven, CT New York, NY Newark, NJ Norfolk, VA Oakland, CA Olympia, WA Orange County, CA Philadelphia, PA Phoenix, AZ Pittsburgh, PA Portland, OR Pueblo, CO Riverside, CA Rochester, NY Sacramento, CA Salem, OR San Antonio, TX San Diego, CA San Francisco, CA San Jose, CA San Luis Obispo, CA Santa Barbara, CA Santa Rosa, CA Seattle, WA Spokane, WA St. Louis, MO State College, PA Stockton, CA Tampa, FL Tucson, AZ Vallejo, CA Ventura, CA Washington, DC West Palm Beach, FL Williamsport, PA Yolo, CA

17,346,623 23,211,347 13,501,598 9,709,749 40,557,970 95,804 383,338 79,465 349,574 68,210 675,488 30,448 992,390 234,212 364,346 55,645 320,470 121,864 222,603 633,601 51,296 176,568 253,660 128,468 27,255 365,462 148,241 237,583 222,203 1,041,786 33,977 324,849 334,042 58,972 435,505 261,503 1,226,556 278,896 190,115 287,541 29,187 308,671 780,562 416,386 456,437 234,214 26,363 397,446 171,225 226,547 51,562 199,746 357,564 253,314 175,312 40,875 57,576 65,692 280,879 61,875 392,040 16,190 72,815 478,592 134,854 65,952 91,404 499,754 250,725 22,062 18,866

% of National Total 43% 57 33 24 — 0.2 0.9 0.2 0.9 0.2 1.7 0.1 2.4 0.6 0.9 0.1 0.8 0.3 0.5 1.6 0.1 0.4 0.6 0.3 0.1 0.9 0.4 0.6 0.5 2.6 0.1 0.8 0.8 0.1 1.1 0.6 3.0 0.7 0.5 0.7 0.1 0.8 1.9 1.0 1.1 0.6 0.1 1.0 0.4 0.6 0.1 0.5 0.9 0.6 0.4 0.1 0.1 0.2 0.7 0.2 1.0 0.0 0.2 1.2 0.3 0.2 0.2 1.2 0.6 0.1 0.0

March 1999 4,589,887 1,475,688 1,265,351 210,337 6,065,575 34,495 39,536 29,612 52,477 21,723 155,797 10,057 133,252 51,667 83,343 15,639 62,790 41,265 95,271 45,798 7,929 53,281 120,782 12,534 7,043 83,505 42,741 54,393 49,821 359,621 5,619 133,827 48,212 24,734 94,964 59,475 209,285 28,591 13,879 114,646 9,620 111,634 243,255 169,277 137,310 106,183 8,492 190,560 25,798 88,287 11,936 57,508 165,261 94,523 67,817 10,038 20,063 27,431 92,808 14,766 94,061 5,902 24,024 164,956 60,267 23,527 32,219 32,738 87,069 7,650 7,303


March 2002 3,928,085 1,029,491 908,768 120,723 4,957,576 32,219 33,648 28,702 7,021 10,246 136,896 8,369 62,328 38,310 64,575 9,492 23,770 38,511 88,250 26,495 6,126 31,961 115,545 14,544 2,011 37,275 21,876 54,378 30,561 348,353 0 147,968 41,246 22,595 59,050 26,970 222,324 17,939 0 108,504 8,889 108,562 236,927 165,894 159,350 98,032 5,023 177,802 39,049 90,437 21,997 51,834 153,630 80,967 64,343 5,716 13,576 27,756 70,151 0 90,212 1,716 21,691 119,904 48,495 22,246 25,736 18,740 73,018 901 7,433


SOURCE: MPR analysis of CMS public-use files (State/County/Plan Market Penetration files and Geographic Service Area files, various dates)

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ENROLLEES AFFECTED BY PULLOUTS 4

MEDICARE+CHOICE PENETRATION RATE

MEDICARE+CHOICE CONTRACTS3

March 1999 March 2002

March 1999 March 2002

27% 7 10 2 15

23% 4 7 1 12

39 11 40 15 34 23 37 14 22 23 30 21 35 45 7 16 32 47 10 27 25 31 24 26 36 17 43 15 45 22 23 17 10 8 41 36 39 32 44 30 47 34 52 15 42 24 30 48 38 40 25 36 43 34 25 24 38 35 35 48 38 38 7 36 35 42

34 9 36 2 15 20 27 6 16 18 17 7 32 40 4 12 18 46 11 7 10 15 23 14 33 0 46 12 38 14 10 18 6 0 38 30 35 30 40 35 42 19 45 23 40 43 26 43 32 37 14 24 42 25 0 23 11 30 25 36 34 28 4 29 4 39

1999

2000

2001

2002

Cumulative5 1999-2002

215 214 189 117 302

113 96 83 63 150

211,968 181,128 143,899 37,229 393,096

156,874 165,982 124,174 41,808 322,856

543,520 343,016 276,136 66,880 886,536

340,520 190,624 173,210 17,414 531,144

1,252,882 880,750 717,419 163,331 2,133,632

4 5 8 4 5 6 5 5 7 11 2 8 3 6 7 2 7 11 2 4 8 4 7 4 11 2 10 3 4 9 8 12 8 1 7 5 11 12 9 4 7 3 10 3 6 4 4 6 8 6 2 3 4 7 3 4 3 4 8 7 2 7 4 11 3 2

3 3 4 2 1 4 2 1 5 7 1 1 2 2 4 2 2 8 1 1 3 2 3 2 8 0 10 2 2 3 2 9 3 0 3 2 7 9 6 4 6 2 8 4 4 4 2 4 4 4 1 3 2 2 0 3 2 2 4 2 2 3 2 7 2 3

0 6,080 441 17,523 2,143 11,252 403 16,944 2 3,943 6,107 3,828 507 6,259 0 0 1,152 0 0 138 8,194 6,073 0 0 1,806 0 0 3,775 0 22,349 5,092 22,922 2,445 0 2,610 105 738 510 0 0 0 0 916 0 715 0 4,246 881 3,638 4,491 2,662 97 40 12,369 5,698 750 0 0 1,085 0 1,314 363 19,362 0 0 0

0 860 451 2,612 9,090 0 1,878 716 0 4,036 162 12,536 492 10,659 0 0 5,609 1,698 0 222 779 0 3,451 12,764 478 1,398 0 2,823 0 12,466 3,065 8,258 2,180 13,809 0 0 100 112 16,052 0 1,015 1,591 601 0 0 0 172 1,646 0 0 3,581 0 0 0 6,810 0 0 0 2,674 5,236 0 2,195 1,409 1,039 149 0

2,109 19,471 0 44,578 7,247 15,783 0 12,347 22,033 29,807 0 35,542 0 425 90 0 18,220 3,477 0 2,415 74,848 11,891 1,788 0 11,432 3,794 1,959 14,159 0 38,998 25,276 5,344 972 0 2,990 311 2,489 1,158 0 2,976 0 0 4,447 0 5,793 0 3,478 0 12,677 2,526 0 0 757 23,309 0 7,522 5,578 2,093 24,798 15,799 0 0 9,250 4,691 6,873 0

0 348 2,527 0 0 12 0 40,539 1,003 3,095 0 16,628 0 9,250 20,425 0 10,651 3,750 1,971 0 1,065 897 6,917 0 1,493 0 0 0 9,381 13,885 15,949 677 5,814 0 12,773 0 78 59,790 10,909 6,224 442 0 10,014 0 2,355 0 805 8,093 12,521 0 0 1,533 2,487 0 9,967 0 0 7,327 12,655 0 3,277 6,956 0 6,037 0 0

2,109 26,759 3,419 64,713 18,480 27,047 2,281 70,546 23,038 40,881 6,269 68,534 999 26,593 20,515 0 35,632 8,925 1,971 2,775 84,886 18,861 12,156 12,764 15,209 5,192 1,959 20,757 9,381 87,698 49,382 37,201 11,411 13,809 18,373 416 3,405 61,570 26,961 9,200 1,457 1,591 15,978 0 8,863 0 8,701 10,620 28,836 7,017 6,243 1,630 3,284 35,678 22,475 8,272 5,578 9,420 41,212 21,035 4,591 9,514 30,021 11,767 7,022 0

Notes: 1. The 66 markets are all U.S. large MSAs with either a population over 1.5 million or a Medicare managed care penetration rate greater than 30 percent in 1998. The market areas follow the Office of Management and Budget's definitions for MSAs, with the exception of Boston, from which three outlying counties in New Hampshire and one in central Massachusetts have been excluded. 2. National totals reflected here are slighly smaller than published CMS statistics due to restrictions involved in creating the analysis file. These include dropping records for enrollees whose addresses do not conform to their plans‘ defined geographic service area and those who are listed as “out of country.” In addition, CMS‘s public-use files omit counts for any cell with fewer than 10 beneficiaries, due to privacy concerns. Records from Puerto Rico and the Virgin Islands were not included. 3. Contract counts are the number of unique contracts in each geographic area. They do not sum down the column since some contracts are in multiple markets. Includes, for various years, contracts of type Medicare+Choice, RISK, RISK C, HMO, PSO, and PPO. Does not include private fee-for-service plans or demonstrations. Four Medicare+Choice contracts that CMS converted to demonstration status in 2002 in order to experiment with payment alternatives are counted as Medicare+Choice contracts here. 4. Enrollees affected by pullouts are those enrolled in an exiting Medicare+Choice plan in June of the prior year. Partial service area reductions are not counted, except in 2002, when CMS began tracking the share of a county's enrollment affected by partials. 5. Counts are not unduplicated; some enrollees were dropped by exiting Medicare+Choice plans multiple times and are counted more than once over the years.

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Strong Managed Care Markets Though few markets were untouched by plan withdrawals between 1999 and 2002, Medicare managed care remains strong in a number of places. Medicare+Choice penetration was 40 percent or more in 10 markets in 2002 (see Table 5). Even in these markets, the 2002 penetration rate generally was the same as or lower than in 1999, though penetration actually grew in a few places. Except for Miami and Salem, OR, each of the markets experienced some reduction in participating plans. Cook et al. (2002) compared characteristics of 20 “troubled” markets to 20 “stable” markets. Troubled markets were those where 30 percent or more of Medicare+Choice enrollees were affected by a withdrawal or service area reduction in any year from 1999 to 2001. In stable markets, only 5 percent of enrollees or less were affected. The two sets of markets initially had similar benefit levels, number of participating plans, and market concentration. But the troubled markets had

Table 5

Top 10 Markets, Medicare+Choice Market Penetration, 2002

1. Ft. Lauderdale, FL 2. Miami, FL 3. Riverside, CA 4. San Diego, CA 5. Salem, OR 6. Santa Rosa, CA 7. Portland, OR 8. Sacramento, CA 9. Phoenix, AZ 10.Denver, CO

Medicare+Choice 1999 Rate

Market Penetration 2002 Rate

47% 43 52 48 24 43 47 42 44 45

46% 46 45 43 43 42 42 40 40 40

11 10 10 6 4 4 7 6 9 6

8 10 8 4 4 2 6 4 6 2


Implications of Market Variation Recent experience highlights the importance of local market features in shaping beneficiaries’ experience with Medicare+Choice. Medicare managed care developed unevenly across the country and is eroding unevenly as well. Many areas of the country, particularly rural communities, historically have had limited Medicare+Choice enrollment

Under current policy, it is likely that Medicare+Choice will continue to diminish nationally, with enrollment increasingly concentrated in those markets where conditions are most hospitable. fewer Medicare+Choice enrollees and lower penetration rates. Over time, the troubled markets experienced a more rapid decline in benefits and a larger increase in market concentration than the stable markets. The decline was driven by plan withdrawals. Concurrent declines in Medicare+Choice enrollment and penetration rates in the troubled markets reflected higher voluntary disenrollment as well as involuntary disenrollment, meaning that beneficiaries were reacting to market instability in both active and passive ways. Quality of care did not vary across the two sets of markets.

Number of Contracts 1999 2002

(MedPAC, 2001; Casey et al., 2002). Most rural residents never had an option to begin with. Even so, rural areas have been affected disproportionately by recent withdrawals from the program. Some large urban areas have had and continue to have many plan options, despite signs that these areas, too, are reflecting national trends with a decline in the number of competing plans and level of benefits and unstable network participation by providers (Achman and Gold, forthcoming). Under current policy, it is likely that Medicare+Choice will continue to diminish nationally, with enrollment increasingly

concentrated in those markets where conditions are most hospitable. Since markets vary, often in ways that federal policy can only marginally influence, a market-based insurance strategy like Medicare+Choice will almost always mean that plan choices vary substantially across the nation. ■

About the Data The data presented are based on analysis of publicly available CMS data. Sources include the state/county/plan market penetration files, files of plan nonrenewals and service area reductions, and the geographic service area file for various quarters. Markets were defined by MSA using methods developed in Cook et al. (2002). The highlighted MSAs have at least 1.5 million people or a managed care penetration rate of 30 percent or greater. We excluded three of the 69 MSAs included in Cook et al. (2002) because they no longer had any plans by 1999. Statistics refer to coordinated care plans and exclude plans participating in Medicare on a cost or demonstration basis. Cumulative totals of enrollees affected by Medicare+Choice withdrawals include some individuals affected more than once over the time period, so the totals are not unduplicated counts of beneficiaries. Full data for each of the 66 markets are displayed in Table 4 on pages 3 and 4.

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REFERENCES Achman, Lori, and Marsha Gold. Medicare+Choice Benefits and Premiums: Trends from 1999-2002. New York: The Commonwealth Fund (forthcoming). Brown, Randall S., and Marsha Gold. “What Drives Medicare Managed Care Growth?” Health Affairs 18(6): 140-149, NovemberDecember 1999. Casey, Michelle, Astrid Knott, and Ira Moscovice. “Medicare Minus Choice: The Impact of HMO Withdrawals on Rural Medicare Beneficiaries.” Health Affairs 21(3): 192-199, May/June 2002. Cook, Anna, Tim Lake, and Bob Schmitz. Early Experience under Medicare+Choice: Final Summary Report. Washington, DC: Mathematica Policy Research, Inc., 2002. Dallek, Geraldine, and Andrew Dennington. Physician Withdrawals: A Major Source of Instability in the Medicare+Choice Program. New York: The Commonwealth Fund, January 2002. Draper, Debra, Marsha Gold, and John McCoy. The Role of National Firms in Medicare+Choice. Washington, DC: Kaiser Family Foundation, June 2002. Gold, Marsha, and John McCoy. “Choice Continues to Erode in 2002.” Fast Facts No. 7, Washington, DC: Mathematica Policy Research, Inc., January 2002. Grossman, Joy M., Bradley C. Strunk, and Robert E. Hurley. Reversal of Fortune: Medicare+Choice Collides with Market Forces. Issue Brief No. 52, Washington, DC: Center for Studying Health System Change, May 2002. Maryland Department of Health and Mental Hygiene (MDHMH). Report in Response to Legislative Request to Study the Cost of Providing Access to Managed Care for Medicare+Choice Eligibles in Maryland. Baltimore, Jan. 11, 2001. Medicare Payment Advisory Commission (MedPAC). Report to Congress: Medicare in Rural America. Washington, DC, June 2001. Stuber, Jennifer, Geraldine Dallek, and Brian Biles. National and Local Factors Driving Health Plan Withdrawals from Medicare+Choice. New York: The Commonwealth Fund, October 2001. Young, Cheryl. “Recent Research Findings on Medicare+Choice.” Operational Insights No. 6. Washington, DC: Mathematica Policy Research, Inc., November 2001.

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Marsha Gold: Project Director, Monitoring Medicare+Choice The Stein Group: Editor designMind: Design