Disenrollment from Medicare
Advantage Health Plans
2005 Qualitative Assessment
Amy Heller, PhD CMS Project Officer
RTI Research Team
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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.
CAHPS®
Overview of the Medicare CAHPS
Disenrollment Reasons Survey
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.
CAHPS®
Annual Voluntary Disenrollment Rates
2004 Total
Voluntary
Rate
Rate Info
2004
Adjusted
Rate
2003
Adjusted
Rate
2002
Adjusted
Rate
2001
Adjusted
Rate
3.46
2.9
2.94
4.03
2.9
Annual
Rate due to
Cost &
Benefits
2.65
2.5
*
*
*
Annual
Rate due to
Care and
Services
0.25
0.96
*
*
*
CAHPS®
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.
CAHPS®
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.
CAHPS®
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.
CAHPS®
Deciding To Leave A Plan
How 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?
CAHPS®
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?
CAHPS®
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?
CAHPS®
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.
CAHPS®
Financial Implications
Cost 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 copayments, most seemed to refer to increased
monthly premiums as their main cost concern.
CAHPS®
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.”
CAHPS®
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.
CAHPS®
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.”
CAHPS®
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.
CAHPS®
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.”
CAHPS®
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.
CAHPS®
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.”
CAHPS®
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.
CAHPS®
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.”
CAHPS®
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.
•CAHPS®
Jeremy Morton, M.A.