Copyright 1999 Federal News Service, Inc.
Federal News Service
AUGUST 4, 1999, WEDNESDAY
SECTION: IN THE NEWS
LENGTH:
5097 words
HEADLINE: PREPARED STATEMENT OF
KAREN
IGNAGNI
PRESIDENT AND CEO, AMERICAN ASSOCIATION OF HEALTH PLANS
BEFORE
THE HOUSE COMMERCE COMMITTEE
HEALTH AND THE ENVIRONMENT
SUBCOMMITTEE
BODY:
I. Introduction
The
members of the American Association of Health Plans (AAHP) appreciate the
opportunity to submit testimony to assist in the Subcommittee's evaluation of
the Medicare+Choice program. AAHP represents more than 1,000 HMOs, PPOs, and
similar network health plans; our membership includes the majority of
Medicare+Choice organizations, which collectively serve more than 75 percent of
beneficiaries in the Medicare+Choice program. Together, AAHP member plans
provide care for more than 150 million Americans nationwide and have strongly
supported efforts to modernize Medicare and give beneficiaries the same health
care choices that are available to working Americans.
Our plans have had a
longstanding commitment to Medicare and to the mission of providing
high-quality, comprehensive, cost-effective services to beneficiaries. Today,
more than 17 percent -- or 6.2 million beneficiaries -- are enrolled in health
plans, up from only six percent just five years ago. Recent research indicates
that health plans are attracting an increasing number of older Medicare
beneficiaries, and that Medicare beneficiaries are remaining in health plans
longer. In addition, near-poor Medicare beneficiaries are more likely to enroll
in health plans than higher-income beneficiaries. These health plans offer
Medicare beneficiaries many benefits that are not covered under fee-for-service
Medicare, such as full year's hospitalization, lower copayments and deductibles,
and prescription drug coverage (Figure 1 ).
With passage of the Balanced
Budget .Act (BBA) two years ago, Congress took significant steps toward the goal
of providing Medicare beneficiaries with expanded coverage choices similar to
those available in the private sector and toward ensuring the solvency of the
Medicare trust fund. The establishment of the Medicare+Choice program was
supported by AAHP and regarded as the foundation for moving forward with a
program design that can be sustained for future generations of Medicare
beneficiaries. Unanticipated events, however, have endangered this foundation
and created structural issues that must be resolved quickly.
II. Current
State of the Medicare+Choice Program
As members of the Subcommittee know,
the first public sign of trouble in the Medicare+Choice program surfaced last
fall when nearly one hundred health plans were forced to reduce or end their
participation in the program, resulting in more than 400,000 beneficiaries
losing their health plan choice. Fifty thousand of these beneficiaries were left
with no other health plan option. At that time, AAHP and others urged the
Administration and Congress to make mid-course corrections, arguing that if
program problems were left unaddressed, more health plans, many of which have
participated in the program for years, would face the same difficult decisions
in 1999 and beyond. The unfortunate reality is that we were right. Just two
weeks ago, the Health Care Financing Administration (HCFA) announced that
327,000 beneficiaries in another ninety-nine health plans would lose their
health plan on January 1, 2000. Of the 327,000 affected beneficiaries, 70,000
will have no choice but to return to the fee-forservice program because there is
no other Medicare+Choice plan in their area.
In addition to these sobering
events, an AAHP survey of its 26 largest members that participate in the
Medicare+Choice program showed that among responding organizations, a
substantial number of beneficiaries who will be able keep their plan next year
will face increased out-of- pocket costs and reductions in benefit levels.
Survey results, which were independently collected and tabulated by Peter D.
Hart Research for AAHP, showed that premium changes to be instituted by 18
companies will affect nearly 1.5 million of the 3.86 million beneficiaries
covered by the survey whose plans will remain in the program next year. Among
these individuals, monthly premiums will increase by $20 or more for 926,009
persons and $40 or more for 400,757 of the 926,009 persons. Monthly premiums
will decrease for just fewer than 12,000 individuals; in all instances, these
decreases will be less than $20. More than 1.3 million enrollees will face an
increase in prescription drug copayments, while just 10,000 enrollees will have
decreased prescription drug copayments next year. Additionally, about 600,000
individuals covered by the survey will face hospital inpatient copayments
averaging $275 next year. 1
III. Sources of Medicare+Choice Program
Instability
The health plans that announced their decisions to leave the
Medicare+Choice program or to reduce benefits did not make their decisions
lightly. Many of these plans worked up to the July 1 st deadline to devise
strategies that would enable them to maintain their current service area, to
stay in the program next year, or to minimize benefit reductions. But for many
of these plans, current problems with the Medicare+Choice payments and increased
regulatory burdens were too overwhelming, and they were forced to reduce their
participation, to withdraw from the program or to scale-back benefits.
Medicare+Choice Payment
The BBA limited the annual rate of growth in
payments to health plans, producing 522.5 billion in savings from the
Medicare+Choice program. In addition, the BBA reduced geographic variation m
payments to encourage the development of coverage choices in areas of the
country with lower payments.
We supported the passage of payment reforms m
the BBA and understood the need to contribute our fair share toward the savings
necessary to stabilize the Medicare Trust Fund. We are deeply concerned,
however, that unintended consequences of higher than anticipated inflation, the
growing gap in funding between the Medicare+Choice and fee-for-service sides of
the program. and administrative actions taken by HCFA affecting Medicare+Choice
payments do not serve the best interests of beneficiaries and were not
anticipated by Congress.
In 1998 and 1999, because of the low national
growth percentage and the inability to achieve budget neutrality, no counties
received blended payment rates. Spending on medical services furnished to
Medicare-eligible military retirees by Department of Veterans Affairs (VA) and
Department of Defense (DoD) hospitals continues to be omitted from the
calculation of Medicare+Choice rates. A few years ago, the Prospective Payment
Advisory Commission (ProPAC) estimated that health care provided in DoD and VA
facilities to Medicare beneficiaries accounts for 3. I percent of the total
resource costs of treating Medicare beneficiaries. ProPAC concludes from its
findings that the omission of the cost of care provided in DoD and VA facilities
to Medicare beneficiaries leads to systematic errors in both the level and
distribution of Medicare managed care payments. H.R. 2447, introduced by
Congressman McDermott, would help address this problem by including these
amounts in Medicare+Choice rate calculations.
In addition, the BBA sought to
begin tackling some of the issues related to Graduate Medical Education (GME)
reform by limiting the number of residents supported by the Medicare program and
by providing incentives to hospitals to reduce the size of their training
programs. However, a central BBA provision, the removal of GME funds from the
calculation of payments to Medicare+Choice organizations, does not appear to
address GME reform goals.
AAHP opposed the removal of GME funds from the
calculation of Medicare+Choice payments, particularly in the absence of broader,
structural reforms to GME financing. AAHP voiced concern that removal of GME
funds could result in premium increases and/or benefit reductions for
beneficiaries enrolled with plans already participating in the program, inhibit
enrollment growth, and at worst could force some plans to leave the program.
This provision was intended to assure that beneficiaries have access to
services at these facilities and that these facilities are compensated for their
teaching costs. Studies show that health plan members do use teaching facilities
and that plan payments for a given case in a teaching hospital greatly exceed
payments for the same case in a non-teaching hospital. Although GME payments are
being removed from Medicare+Choice payments, in many markets, the dominance of
teaching hospitals limits health plans' ability to reflect the carve- out by
making commensurate reductions in payments to teaching hospitals. Consequently,
teaching hospitals are receiving GME payments from the Medicare program as well
as higher payments from health plans. Ultimately, it is the Medicare beneficiary
who bears the burden of these higher payments due to reductions in additional
benefits that they otherwise would receive.
Furthermore, HCFA has chosen to
implement its new risk-adjustment methodology in a manner that
will cut aggregate payments to Medicare+Choice organizations by an estimated
additional $11.2 billion over a five-year period beginning in 2000. This is an
administratively imposed increase in the $22.5 billion savings Congress expected
from the payment methodology as enacted in the BBA. In fact, at the time of the
BBA's approval, the Congressional Budget Office (CBO) did not score the new
risk-adjuster as saving money. More recently, CBO stated that it had "previously
assumed" that the health status-based risk- adjustment in the
Medicare+Choice program would be budget neutral.2
AAHP analysis of
PricewaterhouseCoopers projections of Medicare-- Choice rates m each count' over
the next five years shows that a significant gap opens up between reimbursement
under the fee-for- service program and reimbursement under the Medicare+Choice
program.3 This Medicare+Choice Fairness Gap will be at least $1,000 for two-
thirds of Medicare+Choice enrollees living in the top 100 counties, as ranked by
Medicare+Choice enrollment (Figure 2). This same Fairness Gap will exceed $1,500
per enrollee in major Medicare+Choice markets, including Chicago, Los Angeles,
Miami, New York, Boston, Pittsburgh, Cleveland, St. Louis City, Dallas, and
Philadelphia. In Miami, the Fairness Gap will be $3,500 per enrollee in 2004 and
in Houston the gap will exceed $2,500 per enrollee in 2004. In New Orleans, the
Fairness Gap will exceed $2,600 per enrollee in 2004.
For nearly half of
Medicare+Choice enrollees living in the top 100 counties, government payments to
health plans on behalf of beneficiaries will be 85 percent or less of
fee-for-service Medicare payments in 2004, significantly exceeding estimates of
so-called overpayment due to favorable selection by plans (Figure 3). When AAHP
examined the top 101 to 200 counties as ranked by enrollment, we continued to
find a large Fairness Gap in the smaller markets that plans were expected to
expand into under the policy changes implemented by the BBA. In these counties,
nearly half of Medicare+Choice enrollees live in areas where the Fairness Gap
will be $1,000 or more in 2004.
A large percentage of the Fairness Gap is
attributable to HCFA's new risk-adjuster, the design of which is severely
flawed. Rather than measuring health-status, HCFA's
risk-adjustment measures inpatient hospital utilization. This
design penalizes health plans that use disease management programs designed to
reduce hospitalizations for chronically ill patients who would have otherwise
been treated in inpatient settings. These programs are designed to prevent
costly hospitalizations by treating patients in alternative settings.
An
AAHP analysis of PricewaterhouseCoopers projections that incorporate the effect
of the risk-adjustment methodology, when it is phased-in at 10
percent, indicate that nearly half of current Medicare+Choice enrollees live in
areas in which year 2000 payments will increase by 2 percent or less over 1999
payments. This situation will likely worsen in 2001 when HCFA will base 30
percent of Medicare+Choice payments on its risk-adjustment
methodology. Contrary to ensuring predictability in the new Medicare+Choice
program, the impact of this risk-adjustment methodology will be
to restrict new market entrants and leave beneficiaries with fewer options,
reduced benefits and higher out-of-pocket costs. AAHP has found that the impact
of HCFA's risk-adjuster on Medicare+Choice payments to rural and urban counties
is similar - rural areas with Medicare+Choice beneficiaries are cut by about 6
percent, while urban areas are cut by about 7 percent.
AAHP also has
significant concerns about the funding of the Medicare beneficiary information
campaign. While it is reasonable for health plans and their enrollees to
contribute to funding HCFA's education and information dissemination
initiatives, their contribution should be in proportion to their participation
in the Medicare program. Last year, Medicare risk HMOs and their enrollees
represented 14.3 percent of the program, but shouldered 100 percent of the cost
of the information campaign.
The FY l999 $95 million funding level
represents an annual cost of $2.40 per beneficiaries if it is spread over the
entire .Medicare population of 39 million beneficiaries. It represents an annual
cost of $15.43 per beneficiary if it is spread over only those beneficiaries who
have enrolled in a Medicare+Choice plan. On average, generating the $95 million
authorized by the BBA will require a tax of $1.90 each month for each
beneficiary enrolled in a Medicare+Choice plan (the tax is collected over only
the first nine months of the year). This $1.90 per month per beneficiary tax
represents 18% percent of the average monthly 1998 to 1999 payment increase
under the new BBA payment methodology.
AAHP supports the goal of providing
beneficiaries with accurate information that allows them to compare all options
and select the one that best meets their needs. Last year's campaign did not
meet Congressional expectations. Many beneficiaries received incorrect or
confusing information and some plans were left out of the brochure altogether.
AAHP urges Congress to ask HCFA for an accounting of its use of resources for
educational purposes. We also urge Congress to adopt MedPAC's recommendation to
fund this program through HCFA's operating funds rather than a tax on
Medicare+Choice enrollees. AAHP continues to believe that the entire beneficiary
information program should be reevaluated and streamlined.
HCFA documents
indicate that it has $25 million left from the fees collected last year and has
indicated that next year's appropriation should be offset by this amount. Yet,
HCFA is asking for more in new user fees than the amount collected last year.
Given concerns about the effectiveness of this effort and at a time of growing
instability in the Medicare+Choice program, we strongly urge that the program be
scaled back and realistic goals set. In addition, we urge that the cost of a
redesigned effort be distributed proportionately across the entire
system.Stabilizing Payment Will Help Stabilize the Medicare+Choice Program
The present state of the Medicare+Choice program is not what Congress
expected when the BBA was approved two years ago. Rather than having expanded
coverage choices, beneficiaries face fewer coverage choices. Additional benefits
offered by plans that are not available in the fee-for-service program are being
jeopardized. Some have argued that HCFA overpays health plans and that plans
withdrawing from the market are simply making "business decisions." In response,
first let me say this: overpaid health plans do not leave a market. Overpaid
health plans do not reduce benefits. Second, payment and regulatory requirements
dictate the type of environment in which health plans participate in the
Medicare+Choice "business." So yes, the current payment and regulatory
environment is forcing plans to make difficult business decisions regarding
their participation in the Medicare+Choice program.
The Bilirakis-Deutsch
bill, H.R. 2419, would go a long way toward stabilizing the payment situation in
both urban and rural areas by requiring that HCFA implement the new
risk-adjuster on a budget- neutral basis, which is in keeping with Congressional
intent. The bill also would ensure that national updates to government payments
for beneficiaries choosing a Medicare+Choice plan grow at the same rate as
government payments for beneficiaries choosing fee-for-service Medicare. H.R.
2419 represents an equitable restoration of funding by increasing the total
dollars available in setting Medicare+Choice payment rates. This approach will
help ensure that the BBA goal of expanding coverage choices for all
beneficiaries is met.
Another way that payments could be stabilized is
through establishment of a true payment floor.
As discussed earlier in
this testimony, Medicare+Choice payments are falling drastically relative to
feefor-service Medicare payments - in many areas, payments are falling to 80
percent or less of fee- forservice payment. To prevent this, a true floor could
be set such that Medicare+Choice payments would not fall below a specified
percentage of fee-for-service per capita payments in a county.
Medicare+Choice Regulatory Environment Contributes to Program Volatility
The challenges facing the Medicare+Choice program do not result from payment
alone. HCFA's approach to overseeing the program and the structure of the
Medicare+Choice program are contributing to the volatility in the program. Taken
together, the issues of payment and regulation have challenged plans' abilities
to maintain their health care networks. In some cases, providers simply have
told health plans that given low payments and increased regulatory requirements
on them, that they are better off just seeing beneficiaries under the fee-for-
service program. HCFA Roles as Purchaser and Regulator in Conflict. HCFA's dual
roles as purchaser and regulator are, at times, in conflict. Nowhere has this
conflict been more evident than in HCFA's implementation of the BBA. The
situation plans faced in the fall of 1998 serves to illustrate the inherent
conflict between HCFA's traditional role as a regulator and its changing role as
a purchaser. HCFA published the Medicare+Choice regulation, which was more
burdensome than expected, nearly a month and a half after the date plans were
required to file their 1999 adjusted community rate proposals (ACRs) last year.
This situation and the unrealistic compliance deadlines combined with the
reduced rate of increase in payments and the uncertainty created by the new
risk-adjustment model, caused plans across the country and
across model types to become deeply concerned last fall about the viability of
the benefits and rates-included in their ACRs on the originally mandated May 1st
deadline. This led our members to make an unprecedented request to HCFA to allow
plans to resubmit parts of their ACRs. In some service areas, the ability to
vary copayments -- even minimally -- meant the difference between a plan's
ability to stay in the Medicare+Choice program or to pull out of a market.
While this request presented HCFA with a complicated situation, AAHP
strongly believes that an affirmative decision would have been better for
beneficiaries. As a purchaser, HCFA had a strong motivation to maintain as many
options as possible for beneficiaries by responding to health plans' concerns
and adopting a more flexible approach to Medicare*Choice implementation. As a
regulator, however, HCFA had concerns about criticism that could result from
reopening bids, and thus chose not to allow any opportunity for adjustment of
ACRs. HCFA's decision in part contributed to the withdrawal of nearly 100 health
plans from the program, affecting more than 400,000 beneficiaries. These role
conflicts remain unresolved, even largely unaddressed. Until ways are found to
reconcile them, however, they will stand in the way of designing and delivering
a Medicare+Choice program that really works for beneficiaries.
Need For Fair
Regulations. Beneficiaries should have confidence that all options, including
both Medicare+Choice plans and the Medicare fee-for-service program, meet
standards of accountability that ensure that they will have access to all
Medicare benefits and rights regardless of the coverage choice they make. All
Medicare+Choice options offered to Medicare beneficiaries should be required to
meet comparable standards in such areas as quality of care, access, grievance
procedures, and solvency.
These standards should be implemented through
regulatory requirements that make the best use of plans' resources to ensure
that beneficiaries receive the maximum value from the program. This means that
when requirements are established, their benefits must outweigh their costs.
While we
appreciate HCFA's efforts to address concerns about certain aspects
of the Medicare+Choice regulation over the past several months, the fact remains
that health plans are having to devote substantial human and financial resources
toward compliance activities, which in turn means fewer resources devoted to
additional benefits.
AAHP renews its request that HCFA undertake an
immediate analysis to develop a full understanding of the relationship between
the costs associated with the full array of Medicare+Choice requirements and
their value to beneficiaries and the Medicare program. We believe strongly' that
more of these resources should be available for benefits and patient care.
Specific Areas of Concern with Medicare+Choice Legislative and Regulatory
Requirements.
Beyond the issues presented above the following specific areas
are among those that remain problematic:
Discontinuation of Flexible
Benefits Policy. Prior to enactment of the BBA, Medicare HMOs were allowed to
vary premiums and supplemental benefits within a contracted service area on a
county-by-county basis, and to customize products - or offer "flexible benefits"
- to meet beneficiary and employer needs and the dynamics of individual markets.
The BBA and HCFA's Medicare+Choice regulations are both more restrictive than
this policy, and require that Medicare+Choice plans offer uniform benefits and
uniform premiums across a plan's total service area without regard to different
county payment levels. The result is that plans are less likely to continue or
begin serving lower-payment counties, just the opposite of expanding coverage
choice. HCFA developed a transition policy for existing contractors, which
allows Medicare+Choice organizations to segment service areas and offer multiple
plans in an effort to mitigate the effect of moving away from the flexible
benefits policy. While this transitional relief has alleviated this problem in
the short term, a permanent solution is needed. AAHP encourages the Committee to
revise the statute so as to revert to the prior policy allowing flexible
benefits within plan service areas.
HCFA's QISMC Standards Disregard
Experience of Private Sector. One area of significant concern to AAHP member
plans is HCFA's Quality Improvement System for Managed Care (QISMC). QISMC is
designed to establish a consistent set of quality oversight standards for health
plans for use by HCFA and state Medicaid agencies under the Medicare and
Medicaid programs, respectively. AAHP has long advocated coordination of quality
standards for health plans in order to maximize the value of plan resources
dedicated to quality improvement. While AAHP believes that QISMC could have been
designed to contribute to this important goal, our members have a number of
serious concerns regarding HCFA implementation of this program. Furthermore, we
are also concerned that the Medicare program is not providing equal attention to
the overall quality of care furnished under the fee-for- service program.
One of our primary concerns is that QISMC lacks clear coordination with
existing public and private sector accreditation and reporting standards. Rather
than coordinate with existing standards, QISMC establishes an entirely new
system of requirement that not only are far more stringent, but also are
unreasonable in their timeframes. Meeting two competing sets of standards adds
to administrative cost while detracting from health care quality improvement.
IV. Solving the Problems that Undermine the Success of the Medicare+Choice
Program
AAHP and its members applaud the Subcommittee for holding this
hearing and implore the Subcommittee to move immediately in taking measures to
restore stability to the Medicare--Choice program. In doing so, AAHP members
urge the Subcommittee to consider the following four principles.
First,
Congress must ensure that Medicare+Choice payments are adequate and stable and
that they are comparable to those in fee-for-service Medicare. Federal
contributions to Medicare+Choice organizations should be adequate and
predictable to promote expanded coverage choices for beneficiaries in low
payment areas, while maintaining the availability of affordable options for
beneficiaries in markets in which health plan options are currently well
established. The Administration projects that its approach will cut
Medicare+Choice payments by an additional $11.2 billion over a 5-year period and
thus endanger the very choices, broader benefits, and out-of-pocket protections
these beneficiaries enjoy. As is now apparent, the BBA payment formula, in
combination with the Administration's new risk- adjuster, will not achieve this
goal. Instead, AAHP analysis shows a dramatic gap opening up between payments
for beneficiaries in the Medicare+Choice program and their counterparts in
fee-for-service Medicare.
AAHP urges of swift approval of the bipartisan
H.R. 2419, the Medicare+Choice RiskAdjustment Amendments of 1999, introduced by
Congressman Bilirakis and Congressman Deutsch. A budget-neutral risk- adjuster
brings greater equity to payments without penalizing plans or destabilizing the
program.
Second, HCFA's beneficiary information and education effort
should be re-examined and refocused to meet beneficiary interests and needs.
AAHP supports the goal of providing beneficiaries with accurate information that
allows them to compare all options and select the one that best meets their
needs. AAHP urges Congress to ask HCFA for an accounting of its use of resources
for educational purposes. AAHP continues to believe that the entire beneficiary
information program should be reevaluated and streamlined.
Third, Congress
must promote and enforce a responsive regulatory environment. Without a doubt,
the present instability has undermined beneficiaries' confidence in the
Medicare+Choice program. Unless action is taken to restore their confidence, it
is unlikely that the goals of the BBA will be achieved. Beneficiaries deserve a
well-run program that is responsive to their needs. Unfortunately, the conflict
between HCFA's roles as a purchaser and regulator often prevent the Agency from
acting more nimbly in the best interests of beneficiaries.
HCFA's
implementation of the BBA highlights the tension between these roles. To
increase consumer confidence in all aspects of the Medicare program, HCFA should
take immediate steps to improve administration and regulation of the
Medicare+Choice program. During the first year of Medicare+Choice
implementation, HCFA promulgated more than 800 pages of new regulations and
issued countless operational policy letters. The Medicare+Choice regulation
should be re-examined to ensure that the value to beneficiaries justifies the
resources required for compliance.
V. Conclusion
For over a decade,
health plans have delivered to beneficiaries coordinated care, comprehensive
benefits, and protection against highly unpredictable out-of-pocket costs, but
these coverage choices are at risk. Congress and the Administration should act
immediately to create a level playing field between the payments under the
Medicare+Choice program and the Medicare fee-for-service program, and a
regulatory environment based on the principles of ensuring that the value to
beneficiaries justifies the resources required for compliance and equal
accountability under the Medicare+Choice and Medicare fee- for-service programs.
We urge you to address the Fairness Gap, and the problems we have identified
with HCFA's implementation of the Medicare+Choice risk- adjuster, and with
regulation of the program. We are in the process of conferring with the members
of the Subcommittee and your staff about AAHP's specific suggestions - some of
which we have mentioned today - for solving these problems.
Our concern last
year that without action, more beneficiaries would lose access to their plan and
that others would face reductions in benefits has become a dismal reality.
Further delay could render the Medicare+Choice program beyond repair or salvage.
This outcome would be a loss not only for the beneficiaries who have chosen a
Medicare+Choice plan, but also for future beneficiaries who would be denied the
opportunity to do so. 1 In responding to the survey, plans were asked to provide
information on the benefit arrangement that presently applies to the largest
share of their Medicare+Choice enrollees. Plans were asked to describe the 1999
benefit, any change in the benefit to become effective on January 1, 2000, and
the number of enrollees covered.under the benefit. Using this information, Peter
D. Hart Research estimated the number of enrollees affected by benefit changes
and the magnitude of these changes among the subset of enrollees covered by the
most common benefit arrangement. Not all companies responded to each question.
2 "An Analysis of the President's Budgetary Proposals for FY 2000,"
Congressional Budget Office.
3 AAHP calculation from PricewaterhouseCoopers
(PWC) analysis prepared for AAHP, March 1999. AAHP's analysis produces
conservative estimates of the Fairness Gap by assuming that county-level
Medicare+Choice and FFS payments were equal in 1997, even though Medicare+Choice
payments were actually lower than FFS per capita payments in 1997. PWC analysis
based on first stage of risk adjustment. PWC analysis does not
reflect second stage of risk adjustment, which HCFA expects to
reduce payments by an additional 7.5 percent in 2004. The Fairness Gap
represents growth between 1997 and 2004 in the protected difference between
county-level aged Medicare+Choice risk-adjusted per capita payments and FFS per
capita payments. Top 100 counties by enrollment account for 72 percent of
enrollment.
END
LOAD-DATE: August 5, 1999
