Disenrollment from Medicare Advantage Health Plans

2005 Qualitative Assessment

Amy Heller, PhD CMS Project Officer

RTI Research Team• Lauren McCormack, PhD, M.S.P.H. • Judith Lynch, B.A.• Claudia Squire, M.S.• Jeremy Morton, M.A.• Judith Lynch, B.A.• Lee Mobley, Ph.D.• Philip Salib, B.A.

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Overview of the Medicare CAHPS Disenrollment Reasons Survey

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The Medicare CAHPS® Disenrollment Reasons Survey attempts to determine the specific reasons why beneficiaries voluntarily leave their Medicare Advantage (MA) health plans as well as.

1. Provides information about the comparative performance of MA plans to help beneficiaries make informed Medicare health plan choices;

2. Enhance CMS’ ability to monitor quality of care and performance of MA plans, and

3. Help MA plans identify problems and improve the quality of care and services they provide to beneficiaries by determining reasons why people leave their plan.

Annual Voluntary Disenrollment Rates

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2004 Total Voluntary

Rate

2004 Adjusted

Rate

2003

Adjusted

Rate

2002 Adjusted

Rate

2001 Adjusted

Rate

Rate Info

4.03 2.9 3.46 2.9 2.94Annual Rate due to Cost & Benefits 2.65 2.5 * * *Annual Rate due to Care and Services 0.25 0.96 * * *

Qualitative Study Examined Decision to Disenroll not just Reasons

• Examined factors that influenced the decision to disenroll from a plan and those considered in choosing a new plan

• The role of prescription drug coverage in their disenrollment and enrollment decisions in light of new drug benefit

• Awareness of and feedback on the Medicare Prescription Drug Plan and its effect on future disenrollment/enrollment decisions

• The role of health plan options (MA, HMO, FFS, MA PPO) in disenrollment/enrollment decisions

• Experiences with Medicare plan options since disenrolling from the sample plan.

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Sample Design

Conducting 10 focus groups with 75 Medicare Advantage plan disenrollees in March and April of 2005 across 3 different health care markets:

Philadelphia- 18 beneficiaries, Phoenix – 33 beneficiaries Birmingham- 24 beneficiaries.

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Sample Population

• Wanted to learn more about experiences of:

1. Disabled beneficiaries.

2. Beneficiaries who left their MA plans and went to another MA plan versus returning to FFS Medicare.

3. Beneficiaries who had prescription drug coverage versus those who did not.

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Deciding To Leave A PlanHow participants weighed these, and other factors, in their

decision to leave:

• Cost (e.g., premiums, co-pays)• Coverage issues (e.g., plan benefits)• Access to care issues (e.g., getting appointments as soon as

you wanted, problems or delays in getting approval to see a specialist, etc.)

• Problems getting specific needs met (e.g., getting special medical equipment, or some other type of care needed)

• Difficulty in getting to doctor and health care facilities in your plan (travel- distance from home)

• How did you compare the plan choices in your areas?• How much did the amount of plan choice in your area affect

your decision to leave?• How important was of the quality of care in your decision to

leave?

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Role Of Prescription Drug Coverage In the Decision to Leave

• Try to assess who had at least some prescription drug coverage with their old plan and who has it with their new plan.

• What type of prescription drug coverage, if any, with our old plan?

• How did prescription drug coverage affect your decision to leave?

• If you had prescription drug coverage before, did you try to get it again?

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Assess Awareness of the New Medicare Drug Benefit

• Beginning January 1, 2006, Medicare will cover prescription drugs for Medicare beneficiaries through Medicare Prescription Drug Plans. Insurance companies and other private companies will work with Medicare to offer these drug plans. These plans are different from the Medicare-approved drug discount cards, which will phase out by May 15, 2006, or when your enrollment in a Medicare prescription drug plan takes effect, if earlier.

• How will this new Medicare drug benefit affect your decision to stay with your current plan or to go to another one?

• How interested are you in this new benefit? What do you want to know about it?

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Summary of Findings• Few participants seemed to explicitly weigh a set of

predetermined factors when making a decision to disenroll from a plan or when choosing a new plan.

• These factors included costs, doctors in their plan, prescription drug coverage, hospital coverage, preventive services, quality of care, customer service, emergency coverage out of the country, and ambulance costs.

• Participants across sites identified many of the same sources that they go to for information about a plan. At all three sites identified family members, friends, health care providers, and health plan representatives as good sources of information.

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Financial ImplicationsCost was a reason for leaving the plan mentioned by

participants across sites, different aspects seemed to be more important at one site versus another.

Cost-related concerns combined with other reasons that appeared to drive people to disenroll.

Cost concerns were more often related to co-payments than premiums. However, while participants defined “costs” as monthly premiums, deductibles, and co-payments, most seemed to refer to increased monthly premiums as their main cost concern.

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Financial Implications“I left because they put their prices up. I feel that they

get you into their service telling you one figure, one price and monthly fee and as soon as they’ve got enough people in, they start putting the price up so you change to another plan. The same thing goes on. As soon as they get enough people in, they put their price up and the previous company brings their price down.”

“ They said I could get my medication cheaper so I joined them - and then come to find out it was higher instead of cheaper and I was paying $200 a month for medication. When I went into the hospital to have surgery they didn’t pay the bills and now I have the credit bureau writing me every day about those bills so I went to X and they said I wouldn’t have these problems with prescriptions and hospital bills.”

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Impact of Drug Coverage

While the role of prescription drug coverage in beneficiaries’ decision to disenroll from a health plan varied within sites.

Participants based their decision on whether the medication they needed was on a plan’s formulary and the amount of the co-payment.

Most participants across all sites had at least some drug coverage and those that had coverage under their old plan were likely to choose a new plan that also offered coverage.

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Impact of Drug Coverage

“When I went to X the first year they paid my drug bills and then President Bush put his plan in with a $600 month co-pay or whatever that is. Then X suddenly decided that that was going to be it next year - all they would be paying would be the $600 and generics only. I go through $500 a month in medicines so that didn’t take long - I had to switch to Y which has no drug care and ask the drug companies to help me pay my drug bills. So I have the major ones being paid for by the drug companies.”

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Awareness of the Medicare Prescription Drug Plan

Across all three sites few participants had heard about the new Medicare prescription drug plan that will go into effect on January 1, 2006.

As with other insurance issues, participants across sites were confused about the role Medicare would play versus that of their health plan.

Participants in Philadelphia and Birmingham were interested in learning more about the benefit, while in Phoenix participants in only one of the four groups seemed moderately interested in the prescription drug benefit.

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Awareness of the Medicare Prescription Drug Plan

• “Is it basically going to be Medicare with no HMO? Will you have to have an HMO with it?”

• “Is that the one that you pay the $35 and if you don’t get in on it from the first it will be hard to get in on?”

• “Isn’t it coupled with earnings which in a lot of cases what your gross income is per year and they tie it into that as to what your benefits will be? I think it is and I don’t know if that will be much help for us.”

• “The Donut Plan is where it is 80/20 up until a certain point and then you take on all of it and then the government takes on 100%. The problem is the Donut hole is huge and there is a little bitty part that is the government on either side, at least that is my interpretation of it and I am not wild about it but I haven’t figured it all out.”

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Experiences after Disenrollment

Few in Philadelphia experienced problems with continuity of care. Most who wanted to were able to keep the same doctors and hospitals.

In Phoenix, half of the participants had to switch

doctors when they switched plans and had problems with continuity of care.

In Birmingham most participants were able to keep their doctors, but those that were not able to reported problems with continuity of care such as lack of access to doctors, services, or drugs for several months after disenrollment.

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Experiences after Disenrollment

“When I joined I had to choose a PCP and you had to choose one without knowing any of them. Then you get it and find out it was a family practice group and now I’m 51 years old and I didn’t expect to be in a pediatricians office seeing my doctor…there was just so much you didn’t know and you had to make decisions on a lack of knowledge and lack of communication and you get the salesman saying one thing and the people who make the decisions saying another thing and the people in the doctor’s office saying another thing.”

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Experiences of the Disabled

For the disabled participants, their reasons for leaving appeared to be linked to an issue regarding their specific health care needs and a strong desire to stay with their current doctor and/or hospital.

The disabled and/or low income beneficiaries had the most difficulty in optimizing their choices because they had options available to them that weren’t available to others – and sometimes there were tradeoffs.

For example, one person with disabilities put considerable effort into gathering and analyzing information about various options, and ultimately had to give up freedom over physician choice to obtain the best combination of drug coverage and other benefits.

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Experiences of the Disabled

“Some of our conditions are tied up in our disabilities and tied up in our money which is tied in our doctors and it is all interrelated and when you interrupt one you start knocking things over down the road.”

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Conclusions• Few participants systematically weighed their options when

choosing a new plan and when they did, most considered only immediate concerns.

• Many participants were either actively looking for a better plan or were open to the possibility.

• Few participants had a clear understanding of how Medicare relates to their plan and prescription drug coverage, and few were familiar with the new Medicare drug benefit scheduled to begin in January 2006. Many were concerned that the new Medicare drug benefit would be too expensive.

• Most of the participants had some drug coverage. The importance of getting drug coverage through their Medicare plan varied. Those who got drug benefits through state programs, discount programs offered by drug companies, etc. were less interested in the new drug benefit or in getting

coverage through their current plan. CAHPS®

Thank You to RTI

RTI Research Team

• Lauren McCormack, PhD, M.S.P.H. • Judith Lynch, B.A.• Claudia Squire, M.S.• Jeremy Morton, M.A.• Judith Lynch, B.A.• Lee Mobley, Ph.D.• Philip Salib, B.A.

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