Medicare Compliance & Reimbursement

At least in the Medicare program, for-profit managed care plans provide as much access to expensive medical care as their nonprofit counterparts. So says a study in the Jan. 8 New England Journal of Medicine, which looked at the experiences of more than 3.7 million seniors enrolled in Medicare managed care plans during 1997. Roughly two-thirds of the seniors were distributed among 166 for-profit plans, while the remaining third were in 88 nonprofit plans. Seniors enrolled in for-profit plans received each of 12 common high-cost surgical procedures at least as often as seniors in nonprofits, and for-profit enrollees were actually significantly more likely to get two of the procedures, partial colectomies and closed cholecystectomies, than members of nonprofit plans. Among the other procedures included in the study were hysterectomies, total knee replacements, and coronary-artery bypass grafting. The study's results surprised its authors. "We had expected that pressure to produce profits for investors in the for-profit plans would lead them to restrict use of high-cost procedures by enrollees," explained lead author Eric Schneider of the Harvard School of Public Health in a statement. Fears that for-profits will unreasonably restrict care "may not be justified," Schneider said. "On the other hand, our results also raise questions about whether for-profit plans will be any more effective than not-for-profit plans at controlling health care spending."