Do Hospital Characteristics Predict Racial-and-Ethnic Disparities in Patient Experience? National Results From the HCAHPS Survey.

OBJECTIVE: Assess whether hospital characteristics associated with better patient experiences overall are also associated with smaller racial-and-ethnic disparities in inpatient experience. BACKGROUND: Hospitals that are smaller, non-profit, and serve high proportions of White patients tend to be high-performing overall, but it is not known whether these hospitals also have smaller racial-and-ethnic disparities in care. RESEARCH DESIGN: We used linear mixed-effect regression models to predict a summary measure that averaged eight Hospital CAHPS (HCAHPS) measures (Nurse Communication, Doctor Communication, Staff Responsiveness, Communication about Medicines, Discharge Information, Care Coordination, Hospital Cleanliness, and Quietness) from patient race-and-ethnicity, hospital characteristics (size, ownership, racial-and-ethnic patient-mix), and interactions of race-and-ethnicity with hospital characteristics. SUBJECTS: Inpatients discharged from 4,365 hospitals in 2021 who completed an HCAHPS survey ( N =2,288,862). RESULTS: While hospitals serving larger proportions of Black and Hispanic patients scored lower on all measures, racial-and-ethnic disparities were generally smaller for Black and Hispanic patients who received care from hospitals serving higher proportions of patients in their racial-and-ethnic group. Experiences overall were better in smaller and non-profit hospitals, but racial-and-ethnic differences were slightly larger. CONCLUSIONS: Large, for-profit hospitals and hospitals serving higher proportions of Black and Hispanic patients tend to be lower performing overall but have smaller disparities in patient experience. High-performing hospitals might look at low-performing hospitals for how to provide less disparate care whereas low-performing hospitals may look to high-performing hospitals for how to improve patient experience overall.

Rates of Disenrollment From Medicare Advantage Plans Are Higher for Racial/Ethnic Minority Beneficiaries.

BACKGROUND: Each year, about 10% of Medicare Advantage (MA) enrollees voluntarily switch to another MA contract, while another 2% voluntarily switch from MA to fee-for-service Medicare. Voluntary disenrollment from MA plans is related to beneficiaries' negative experiences with their plan, disrupts the continuity of care, and conflicts with goals to reduce Medicare costs. Little is known about racial/ethnic disparities in voluntary disenrollment from MA plans. OBJECTIVE: The objective of this study was to investigate differences in rates of voluntary disenrollment from MA plans by race/ethnicity. SUBJECTS: A total of 116,770,319 beneficiaries enrolled in 736 MA plans in 2015. METHODS: Differences in rates of disenrollment across racial/ethnic groups [Asian or Pacific Islander (API), Black, Hispanic, and White] were summarized using 4 types of logistic regression models: adjusted and unadjusted models estimating overall differences and adjusted and unadjusted models estimating within-plan differences. Unadjusted overall models included only racial/ethnic group probabilities as predictors. Adjusted overall models added age, sex, dual eligibility, disability, and state of residence as control variables. Between-plan differences were estimated by subtracting within-plan differences from overall differences. RESULTS: Adjusted rates of disenrollment were significantly (P<0.001) higher for Hispanic (+1.2 percentage points), Black (+1.2 percentage points), and API beneficiaries (+2.4 percentage points) than for Whites. Within states, all 3 racial/ethnic minority groups tended to be concentrated in higher disenrollment plans. Within plans, API beneficiaries voluntarily disenrolled considerably more often than otherwise similar White beneficiaries. CONCLUSION: These findings suggest the need to address cost, information, and other factors that may create barriers to racial/ethnic minority beneficiaries' enrollment in plans with lower overall disenrollment rates.

The development of a patient-reported functional limitations index.

OBJECTIVES: To develop an easy-to-interpret, patient-reported Functional Limitations Index (FLI) that can be used to assess and monitor the full spectrum of functioning in a community-dwelling population. STUDY DESIGN: Observational design using nationally representative survey data. METHODS: We used self-rated health as a criterion for empirically assigning weights to 5 National Health Interview Survey items assessing difficulty with seeing, hearing, walking, cognition, and self-care. In addition to succinctly summarizing cumulative limitations, we addressed 2 main questions: (1) Which limitations have stronger associations with self-rated health? and (2) How does severity (from 0, no difficulty, to 3, unable to do) relate to self-rated health? We generated a respondent-level summary score based on a model predicting self-rated health from the 5 linearly scored (0-3) items and used splines to account for nonlinear severity-self-rated health associations. RESULTS: The strongest association of specific functional limitations with self-rated health involved mobility; the weakest associations involved sensory limitations. The association of severity with self-rated health was nonlinear and largest moving from no difficulty to somewhat difficult. Nationally, 5% of noninstitutionalized adults were considered most limited, 8% somewhat limited, and 87% least limited. Great mobility limitations (defined as a lot of difficulty or unable to do) most distinguished limitation groups (present in 0% of least limited, 25% of somewhat limited, and 70% of most limited). CONCLUSIONS: The FLI is an easy-to-administer, easy-to-interpret, and valid summary measure of disability that health plans and health care organizations can use for quality-of-care monitoring across a variety of settings to improve care for patients with disabilities.

Using Ancillary Sociodemographic Data to Identify Sexual Minority Adults Among Those Responding "Something Else" or "Don't Know" to Sexual Orientation Questions.

BACKGROUND: General population surveys are increasingly offering broader response options for questions on sexual orientation-for example, not only gay or lesbian, but also "something else" (SE) and "don't know" (DK). However, these additional response options are potentially confusing for those who may not know what the terms mean. Researchers studying sexual orientation-based disparities face difficult methodological trade-offs regarding how best to classify respondents identifying with the SE and DK categories. OBJECTIVES: Develop respondent-level probabilities of sexual minority orientation without excluding or misclassifying the potentially ambiguous SE and DK responses. Compare 3 increasingly inclusive analytic approaches for estimating health disparities using a single item: (a) omitting SE and DK respondents; (b) classifying SE as sexual minority and omitting DK; and (c) a new approach classifying only SE and DK respondents with >50% predicted probabilities of being sexual minorities as sexual minority. MATERIALS AND METHODS: We used the sociodemographic information and follow-up questions for SE and DK respondents in the 2013-2014 National Health Interview Survey to generate predicted probabilities of identifying as a sexual minority adult. RESULTS: About 94% of the 144 SE respondents and 20% of the 310 DK respondents were predicted to identify as a sexual minority adult, with higher probabilities for younger, wealthier, non-Hispanic white, and urban-dwelling respondents. Using a more specific definition of sexual minority orientation improved the precision of health and health care disparity estimates. CONCLUSIONS: Predicted probabilities of sexual minority orientation may be used in this and other surveys to improve representation and categorization of those who identify as a sexual minority adult.

Explaining the Relationship Between Minority Group Status and Health Disparities: A Review of Selected Concepts.

Purpose: There is growing concern that value-based payment for health care may disadvantage health care organizations that serve populations with social risk. In the broader investigation of social risk factors, including income, education, neighborhood deprivation, and other risks, the focus on race and ethnicity as a risk factor for disparities in health and health care has diminished. Understanding the independent contribution of minority group status is critical to this discussion. This narrative review discusses four concepts-minority stress, resilience, epigenetics, and life course-that may help explain the contribution of minority group status and its association with health disparities. Methods: We briefly describe each concept and the supporting evidence. Results: Our results indicate that all four concepts have potential relevance for understanding and addressing health disparities. The life course perspective emphasizes the importance of understanding explanatory mechanisms and factors that contribute to health-including biological, physical, and social factors-over a person's life span. Both minority stress and resilience may influence health in either a negative or positive manner that potentially underlies health changes. Exposure to these factors and others may interact with and modify epigenetic regulation-biological processes that impact how our genes are expressed. This may increase the risk of disease and negative health outcomes, particularly among groups that may be at disproportionate risk because of social circumstances and environmental exposure over the life course. Conclusion: Despite these concepts' relevance, more research is needed to assess how they may explain the relationship between minority status and disparities in health. Such evidence is needed to focus interventions and to inform the design of delivery and payment models that can spur actions to reduce disparities.

An Integrated Approach to Measuring Sexual Orientation Disparities in Women's Access to Health Services: A National Health Interview Survey Application.

PURPOSE: The extent to which disparities affect all sexual minority women (SMW) versus specific subgroups of lesbian, bisexual, or other women remains unclear, in part due to inconsistent analysis of available data. We propose an integrated approach that aggregates subgroups to maximize power to detect broadly applicable disparities, then tests for subgroup heterogeneity, exercising caution with disaggregation when there is no direct evidence of heterogeneity. METHODS: Multivariate analyses of 2014-2015 National Health Interview Survey data examined six barriers to care. We compared heterosexual women (n = 36,474) with SMW (n = 1048) overall and tested for heterogeneous outcomes among subgroups of SMW compared with heterosexual women and with each other. RESULTS: Controlling for sociodemographics and health status, aggregated analyses showed that SMW were more likely than heterosexual peers to have trouble finding a provider (adjusted percentages 5.1% vs. 3.2%, p < 0.01) and no optimal usual place of care (14.5% vs. 11.2%, p < 0.01). There was no evidence of subgroup heterogeneity for either barrier, suggesting uniform disparities for SMW. In contrast, only lesbian/gay women were more likely than heterosexual women to be told their health insurance was not accepted (p = 0.03); this was the only outcome for which the adjusted difference between bisexual and lesbian/gay women was significant (2.8% vs. 6.3%, p = 0.02). CONCLUSION: Analyses that only disaggregated data would have understated overall sexual minority disparities and perhaps overstated subgroup differences; an integrated approach can more accurately characterize disparities experienced by all SMW versus those specific to certain subgroups. Large national surveys should include sexual orientation questions to support adequately powered comparisons.

National racial/ethnic and geographic disparities in experiences with health care among adult Medicaid beneficiaries.

OBJECTIVES: To investigate whether health care experiences of adult Medicaid beneficiaries differ by race/ethnicity and rural/urban status. DATA SOURCES: A total of 270 243 respondents to the 2014-2015 Nationwide Adult Medicaid Consumer Assessment of Healthcare Providers and Systems Survey. STUDY DESIGN: Linear regression was used to estimate case mix adjusted differences in patient experience between racial/ethnic minority and non-Hispanic white Medicaid beneficiaries, and between beneficiaries residing in small urban areas, small towns, and rural areas vs large urban areas. Dependent measures included getting needed care, getting care quickly, doctor communication, and customer service. PRINCIPAL FINDINGS: Compared with white beneficiaries, American Indian/Alaska Native (AIAN) and Asian/Pacific Islander (API) beneficiaries reported worse experiences, while black beneficiaries reported better experiences. Deficits for AIAN beneficiaries were 6-8 points on a 0-100 scale; deficits for API beneficiaries were 13-22 points (P's < 0.001); advantages for black beneficiaries were 3-5 points (P's < 0.001). Hispanic white differences were mixed. Beneficiaries in small urban areas, small towns, and isolated rural areas reported significantly better experiences (2-3 points) than beneficiaries in large urban areas (P's < 0.05), particularly regarding access to care. Racial/ethnic differences typically did not vary by geography. CONCLUSIONS: Improving experiences for racial/ethnic minorities and individuals living in large urban areas should be high priorities for policy makers exploring approaches to improve the value and delivery of care to Medicaid beneficiaries.

Inpatient care experiences differ by preferred language within racial/ethnic groups.

OBJECTIVE: To describe differences in patient experiences of hospital care by preferred language within racial/ethnic groups. DATA SOURCE: 2014-2015 HCAHPS survey data. STUDY DESIGN: We compared six composite measures for seven languages (English, Spanish, Russian, Portuguese, Chinese, Vietnamese, and Other) within applicable subsets of five racial/ethnic groups (Hispanics, Asian/Pacific Islanders, American Indian/Alaska Natives, Blacks, and Whites). We measured patient-mix adjusted overall, between- and within-hospital differences in patient experience by language, using linear regression. DATA COLLECTION METHODS: Surveys from 5 480 308 patients discharged from 4517 hospitals 2014-2015. PRINCIPAL FINDINGS: Within each racial/ethnic group, mean reported experiences for non-English-preferring patients were almost always worse than their English-preferring counterparts. Language differences were largest and most consistent for Care Coordination. Within-hospital differences by language were often larger than between-hospital differences and were largest for Care Coordination. Where between-hospital differences existed, non-English-preferring patients usually attended hospitals whose average patient experience scores for all patients were lower than the average scores for the hospitals of their English-preferring counterparts. CONCLUSIONS: Efforts should be made to increase access to better hospitals for language minorities and improve care coordination and other facets of patient experience in hospitals with high proportions of non-English-preferring patients, focusing on cultural competence and language-appropriate services.

Health Quality Measures Addressing Disparities in Culturally and Linguistically Appropriate Services: What are Current Gaps?

PURPOSE: Disparities in health care persist among many at-risk groups. This study examines the current state of health quality measures addressing disparities and culturally and linguistically appropriate services (CLAS), and identifies important gaps in existing measures and their implementation. METHODS: We searched key quality reporting databases and websites to identify measures and structural program requirements addressing disparities or CLAS. We also conducted a dozen semi-structured interviews to obtain expert perspectives. RESULTS: Twenty-four measures and eight private or public-sector programs with relevant structural requirements were identified. Half the measures focused on language needs. Few measures were used in national reporting programs and adoption of requirements has been limited. Barriers to implementation included lack of data among health plans, lack of health workforce training, and challenges in defining cultural competence. CONCLUSIONS: Future efforts should seek to enhance implementation of existing quality measures addressing disparities and CLAS, and address barriers to their adoption.

Data On Race, Ethnicity, And Language Largely Incomplete For Managed Care Plan Members.

The Affordable Care Act requires the federal government to collect and report population data on race, ethnicity, and language needs to help reduce health and health care disparities. We assessed data availability in commercial, Medicaid, and Medicare managed care plans using the Healthcare Effectiveness Data and Information Set. Data availability varied but remained largely incomplete.

Supporting Human Papillomavirus Vaccination in Adolescents: Perspectives From Commercial and Medicaid Health Plans.

CONTEXT: An estimated 79 million Americans are infected with human papillomavirus (HPV). Vaccination can reduce the burden of infection and HPV-associated cancers; yet, vaccination rates remain low. Little is known about why some health plans achieve higher vaccination rates. OBJECTIVE: This study sought to identify strategies used by higher-performing health plans to support HPV vaccination. DESIGN: We used 2013 data from the Healthcare Effectiveness Data and Information Set (HEDIS) Human Papillomavirus Vaccine for Female Adolescents measure to identify high-performing plans. The measure examines the percentage of female adolescent plan members who received 3 doses of HPV vaccine by their 13th birthday. High performers were defined as the subset of commercial plans with the top 10 rates and the subset of Medicaid plans with the top 10 rates. An interview guide was developed to assess activities related to providing HPV vaccination. Interviews were conducted with selected plans and audio-recorded. Transcripts were reviewed independently by 2 interviewers and analyzed by hand to identify key themes. PARTICIPANTS: Staff members representing 10 plans agreed to be interviewed, representing a diversity of plan size (range, 5500 to >2.7 million members); plan type (about half were commercial, half were Medicaid plans); patient population, from predominantly white to predominantly nonwhite; and geographic region. RESULTS: Plans Participants highlighted multiple strategies that support HPV vaccination, particularly the "normalizing" of the vaccine. Plans' efforts highlighted patient and provider education, reminders, feedback loops, community collaborations, immunization registries, and use of medical home concepts-including team-driven efforts and coordination. IMPLICATIONS: There is an important need to improve the uptake of HPV vaccination. As health coverage expands to more organizations and individuals, it will be critical for health plans to consider the strategies implemented by higher-performing organizations. CONCLUSION: Although HPV immunization rates are low nationally, health plans can employ multiple efforts to encourage vaccination by implementing activities that involve the patient, the provider, and the community.

Shortening a Patient Experiences Survey for Medical Homes.

The Consumer Assessment of Healthcare Providers and Systems-Patient-Centered Medical Home (CAHPS PCMH) Survey assesses patient experiences reflecting domains of care related to general patient experience (access to care, communication with providers, office staff interaction, provider rating) and PCMH-specific aspects of patient care (comprehensiveness of care, self-management support, shared decision making). The current work compares psychometric properties of the current survey and a proposed shortened version of the survey (from 52 to 26 adult survey items, from 66 to 31 child survey items). The revisions were based on initial psychometric analysis and stakeholder input regarding survey length concerns. A total of 268 practices voluntarily submitted adult surveys and 58 submitted child survey data to the National Committee for Quality Assurance in 2013. Mean unadjusted scores, practice-level item and composite reliability, and item-to-scale correlations were calculated. Results show that the shorter adult survey has lower reliability, but still it still meets general definitions of a sound survey for the adult version, and resulted in few changes to mean scores. The impact was more problematic for the pediatric version. Further testing is needed to investigate approaches to improving survey response and the relevance of survey items in informing quality improvement.

Beyond black and white: race/ethnicity and health status among older adults.

OBJECTIVES: This study examined physical and mental health, health symptoms, sensory and functional limitations, risk factors, and multimorbidity among older Medicare managed care members to assess disparities associated with race/ethnicity. STUDY DESIGN AND METHODS: We used data on 236,289 older adults from 208 Medicare plans who completed the 2012 Medicare Health Outcomes Survey to compare 14 health indicators across non-Hispanic whites, blacks, American Indians/Alaskan Natives, Asians, Native Hawaiians/Pacific Islanders, multiracial individuals, and Hispanics. Logistic regression models that clustered on the plan estimated the risk of indicators of adverse health and functional status. RESULTS: Even after controlling for key patient sociodemographic factors, race/ethnicity was significantly associated with most adverse health indicators. Except for Asians, all racial/ethnic minority groups were significantly more likely than whites to report poor mental health status, presence of most health symptoms, sensory limitations, and activities-of-daily-living disability. Important differences were observed across racial and ethnic groups. CONCLUSIONS: Despite some exceptions, elders of racial/ethnic minority background are generally at higher risk than non-Hispanic whites for a broad range of adverse health and functional outcomes that are not routinely assessed. Limitations include bias related to self-reported data and respondent recall. Future research should consider ethnic subgroup variations; employing newer techniques to improve estimates for smaller groups; and prioritizing and identifying opportunities for care improvement of diverse enrollee groups by considering specific needs. To improve the health status of the elderly, service delivery targeting the needs of specific population groups, coupled with culturally appropriate care for racial/ ethnic minorities, should also be considered.

Multiple risk factors and the likelihood of patient-physician communication and health maintenance services in medicare health plans.

This study examined both individual and combined effects of race, education, and health-based risk factors on health maintenance services among Medicare plan members. Data were from 110 238 elderly completing the 2006 Medicare Health Outcomes Survey. Receipt of recommended patient-physician communication and interventions for urinary incontinence, physical activity, falls, and osteoporosis was modeled as a function of risk factors. Low education decreased the odds of receiving services; poor health increased odds. Race had little effect. Evidence suggested moderation among competing effects. While clinicians target services to most at-risk elderly individuals, patients with low education experience gaps. Synergies among co-occurring risks warrant further research.

Identifying older adults at high risk of mortality using the Medicare health outcomes survey.

The Vulnerable Elders Survey (VES), a screening tool for at-risk elderly, has been validated in the community. This study used VES-based criteria to develop a modified version that can be calculated from the Medicare Health Outcomes Survey (HOS) to identify Medicare members at high risk of mortality. Data were from 97,258 HOS respondents in 164 plans. Using age, self-rated health, and function items from the 2005 HOS, an a priori approach modeled on VES scoring and items predicted two-year mortality (c-statistic 0.74). Routinely-collected Medicare survey data may be used to assess patterns of enrollment of high-risk beneficiaries across health plans.

Medicare Part D and quality of prescription medication use in older adults.

In 2006, the US Centers for Medicare and Medicaid Services implemented Medicare Part D to provide outpatient prescription drug insurance to disabled and older adults. In creating Part D, a key provision to address quality included medication therapy management (MTM) programmes designed to increase proper and safe use of medications among targeted Part D beneficiaries. A preponderance of evidence shows that Part D has increased medication affordability and accessibility; however, what remains less clear is whether it has improved the quality of medication use and optimized health outcomes. Now in its sixth year, Part D is undergoing its first major revision, with the gradual elimination of the coverage gap by 2020. Therefore, now is a good time to review the accumulated evidence on the impact of Part D and MTM programmes on the quality of medication use to help inform future policy decisions and research directions. In this review, we found that Part D's net effect on quality of medication use has mainly been positive. Cost-related medication nonadherence improved moderately and there were fewer than expected treatment interruptions. However, vulnerable subgroups, such as sicker and dual-eligible beneficiaries, experienced lags in improvement. Beneficiaries who entered the coverage gap consistently experienced interruptions and displayed worsening medication adherence after entering the gap, with generic-only gap drug coverage offering limited benefit. Such findings can serve as baseline information as the coverage gap phases out. Limited availability of data is the greatest barrier to research into Part D. Part D's overall effect on health outcomes and adverse medical events, such as hospitalizations, is inconclusive because of inadequate evidence to date. Similarly, no evaluation of quality of medication use is available with respect to utilization management strategies and MTM programmes delivered under Part D. Future research will need to further examine the added value of Part D and address whether Part D optimizes health outcomes in the Medicare population. As the current economic recession increases the pressure to cut costs, the effect of future spending restrictions, such as restrictions on coverage subsidies, will also be of special concern.

Self-reported delays in receipt of health care among women with diabetes and cardiovascular conditions.

PURPOSE: Midlife and older adults have high rates of chronic conditions, and differences in health insurance coverage may affect their access to care. Women may be particularly at risk for access problems. This study examines the association of gender and health insurance status with delays in care, a dimension of access to care, among midlife (age 45-64) and older (age > or = 65) adults with diabetes and cardiovascular conditions. METHODS: Data were from the 2004 through 2006 national Medical Expenditure Panel Survey. A total of 4,706 adults with self-identified diabetes and 17,636 adults with self-identified cardiovascular conditions, aged 45 years and older, were included. The analyses examined associations of gender and insurance status with self-reported delays in medical care, dental care, prescription medication, and illness/injury care, using bivariate and multivariate analyses adjusted for race/ethnicity, education, income, and perceived health status. MAIN FINDINGS: Midlife women with diabetes or cardiovascular conditions were more likely to report delays in care than men, even after adjusting for key factors (85%-111% higher odds of delays among diabetes patients, 56%-84% higher odds of delays among cardiovascular patients; all p < .01). Many, but not all, of these gender differences were eliminated among Medicare-insured older adults. Among midlife adults, health insurance coverage differences were also significantly associated with delays in care. CONCLUSION: Women are more likely to experience delays in health care, even after adjusting for health coverage. Efforts are needed to understand factors that influence gender differences in these delays and to determine whether policy reforms eliminate or exacerbate these differences.

Association of Health Plans' Healthcare Effectiveness Data and Information Set (HEDIS) performance with outcomes of enrollees with diabetes.

BACKGROUND: Few quality of care evaluations examine the relationship between clinical processes and patient outcomes. OBJECTIVE: To determine the association between health plan performance on Healthcare Effectiveness Data and Information Set (HEDIS) clinical processes and intermediate outcome measures and Health Outcomes Survey (HOS) self-reported physical and mental health scores among Medicare plan enrollees with diabetes. RESEARCH DESIGN: Secondary data analysis of 2002 HEDIS and 2001-2003 HOS data. SUBJECTS: This study focused on Medicare plan enrollees with self-reported diabetes (N = 8184). MEASURES: Plan-level HEDIS diabetes care measures for 2002 and longitudinal, patient-level 2001-2003 HOS physical and mental health outcomes scores. Hierarchical linear models estimated the relationship between plan HEDIS performance on diabetes process of care and intermediate outcome measures and 2-year changes in enrollee HOS physical and mental health scores. RESULTS: Each 10% point improvement in plan performance on HEDIS intermediate outcomes (ie, the proportion of well-controlled diabetes) was related to significant positive increase in the probability of being healthy as measured by both enrollee physical health scores (7 percentage point increase, P < 0.05) and mental health scores (11 percentage point increase, P < 0.01). Similar increases in plan process of care measures were associated with increases in the probability of being healthy as measured by enrollee mental health scores (11 percentage point increase, P < 0.001). CONCLUSIONS: This study represents one of the first attempts to link plan HEDIS performance to changes in enrollee health. The results suggest that improved quality of care, as measured by process and intermediate outcomes measures for diabetes, can result in better health among patients with diabetes. Further research should address whether this relationship exists in other quality measures, clinical conditions, and populations.

Predictors of voluntary disenrollment from Medicare managed care.

BACKGROUND: Prior research on selection bias in Medicare plans has demonstrated favorable enrollment of healthier beneficiaries, resulting in plan overpayment. However, total selection bias depends not only on who enrolls, but also on who disenrolls. Few studies examine selectivity in disenrollment; it is unclear how those who leave plans differ from those who remain. OBJECTIVE: The examination of health status and plan characteristics as potential predictors of voluntary disenrollment from Medicare managed care. RESEARCH DESIGN: Baseline data on health of Medicare managed care enrollees are from the 1998 Medicare Health Outcomes Survey, merged with data on enrollment status and plan characteristics. Beneficiary voluntary disenrollment, versus continuous enrollment, 24 months after completing the survey was modeled as a function of perceived health in 1998 and plan characteristics. The sample included 109,882 community-dwelling elderly. RESULTS: Between 1998 and 2000, 24% of Medicare managed care enrollees voluntarily disenrolled from plans. Poor perceived physical and mental health significantly increased the odds of voluntary disenrollment. Odds of disenrollment were higher for members of plans that increased premiums and had low market share between 1998 and 2000. Conversely, gaining drug coverage in a plan between 1998 and 2000 lowered the odds of disenrollment (relative to no coverage). CONCLUSION: Medicare plans experience favorable selection bias partly because sicker members are likelier to disenroll. Plan-level policies that influence market share and benefits, particularly pharmaceutical coverage, also have important effects on disenrollment, regardless of health effects. Understanding both individual and plan influences on disenrollment is critical to benefit coverage and disenrollment restriction ("lock in") policies.