Study: Medicaid users not informed Study of Medicaid managed care enrollment found beneficiary awareness lacking

The July 2021 launch of the state Medicaid managed care initiative may have been lacking in raising awareness to between 1.6 million and 1.8 million potential beneficiaries, according to a Wake Forest University School of Medicine report.

Managed care is a system under which people agree to see only certain doctors or go to certain hospitals, as in a health maintenance organization, or HMO, or a preferred provider organization, or PPO, health-insurance plan.

Beneficiaries were told they would be able to keep their primary care provider in most instances.

Part of the initiative's appeal was beneficiaries could choose which statewide prepaid health plan (PHP) they want for physical and behavioral health coverage, or one would be chosen for them.

The NC Medicaid Enrollment Broker program provides choice counseling to help beneficiaries determine which health plan is best for them.

The state pays a set amount per beneficiary each month to the private plan, and then the plan pays for any health-care services.

The PHPs are operated by Centene (operating as WellCare of N.C.), AmeriHealth Caritas N.C., Blue Cross and Blue Shield of N.C. (operating as Healthy Blue) and UnitedHealth Group.

The N.C. Department of Health and Human Services signed three-year PHP contracts projected to be worth a combined $6 billion a year. With two optional one-year extensions, a contract could be worth a total of $30 billion - among the largest vendor contracts awarded in state history.

However, the initiative was only as promising and effective as the beneficiaries' awareness of the transition away from the fee-for-service Medicaid model.

DHHS said in a statement that it has not currently reviewed this study.

"But, as other studies have highlighted, NCDHHS considers the initial transition to managed care, in the midst of the COVID pandemic, to be a success," according to the statement.

"With a specific focus on what our enrolled members and providers would experience, the department was pleased that we were able to transition to managed care in a way that allowed 97% of the 1.6 million beneficiaries to retain their primary care provider.

"NCDHHS works with partners and the health plans to continually improve care and delivery of services based on feedback from beneficiaries and providers."

Measuring goals

Researchers at Wake Forest University School of Medicine decided to measure the level of Medicaid managed care awareness in Forsyth County. The findings were published in the Journal of General Internal Medicine.

The research team analyzed data from surveys and health medical records of Medicaid enrollees receiving primary care within the Atrium Health Wake Forest Baptist network. They identified 4,859 Medicaid enrollees and 5,137 individuals with private insurance, along with survey data from 398 Medicaid enrollees in Forsyth.

Researchers collected data on engagement in managed care plan selection, continuity of care, receipt of social need services and primary care use.

One of the main findings they found was that a large proportion of enrollees were not only unaware of the transition process, but not engaged in their choice of plans.

"We were surprised to find that most - 77.3% - of the Medicaid enrollees reported that the managed care plan they were on was not chosen by them, but automatically assigned to them," said Amresh Hanchate, corresponding author of the study and a professor of social sciences and health policy at the medical school.

"With such a major change affecting a vulnerable population, there was concern about enrollee awareness and engagement in the transition to the new private plans and continuity of care with their providers," Hanchate said.

Other findings

Researchers also found that while the new plans were responsible for screening and providing assistance for social needs, such as food and transportation, 79% reported not receiving any social need assistance.

Other key findings:

19.2% reported lacking assistance with plan choice;13.1% of enrollees reported insufficient information about the transition; and5.9% were assigned to a different primary care provider.

Researchers also conducted focus groups with 22 Medicaid beneficiaries from January to March to gain insight into their experiences with the transition. These findings were recently published in N.C. Medical Journal.

The team identified four major themes from the focus groups: participants expressed confusion about the signup process; had a limited understanding of their new plans; expressed difficulty accessing services through their plans; and primarily noted negative changes to their care.

"Many enrollees expressed fear and confusion related to using their new plans because they were unsure that services would be covered and had trouble reaching a Medicaid representative to help them navigate their services," said Rachel Zimmer, assistant professor of gerontology and geriatric medicine at the medical school.

"Many participants also did not know about the new additional services covered by their plans, such as YMCA memberships or coverage for over-the-counter medicines."

Zimmer said the focus group findings suggest that plan participants felt unsupported during the enrollment process.

Researchers said their study findings "may inform the implementation of future policy changes, including North Carolina's Medicaid expansion" that remains on hold awaiting the passage of the 2023-24 state budget currently being negotiated by House and Senate Republican legislative leaders.

"As Medicaid managed care becomes more established, we hope to see an improvement in the awareness of the policy and choices relating to plans," Hanchate said.

"There also needs to be more assistance for social needs to gain better enrollee engagement, which will hopefully lead to improved patient experience, greater health care access and improved patient outcomes."

Not surprising

The Wake Forest report is not all that surprising given that in May 2021, two months before the launch of managed care, the first sign-up period drew an underwhelming - but expected - response.

At that time, DHHS reported 181,046 beneficiaries had selected a plan.

"From what I have seen and been told, this is about normal based on other state's experience moving to managed care," Rep. Donny Lambeth, R-Forsyth, and a lead proponent of the Republican initiative, said in May 2021.

All health plans are required to have the same Medicaid services, such as office visits, blood tests and X-rays. Health plans each have their own network of qualified doctors and health care professionals.

According to DHHS, "a small number (of beneficiaries) will stay in the current Medicaid system because of the type of services they need, such as those only in the family planning program."

Others who don't have to switch include people who get Innovations Waiver services, traumatic brain injury waiver services or are part of the Community Alternatives Program for Children or Community Alternative Program for Disabled Adults. Those individuals will remain in N.C. Medicaid Direct.

Essential health services will continue to be covered under Medicaid Managed Care, including: primary care and hospital services; mental health and substance use services; pregnancy and childbirth; prescription drugs; and long-term services and supports.

[email protected]@rcraverWSJ