Challenges in obtaining high-quality care surpass concerns about expenses, U-M research reveals
Currently, a majority of senior Americans receive their Medicare benefits via an insurance provider’s Medicare Advantage program. However, many opt to change plans or revert to traditional Medicare during Open Enrollment each autumn.
Scholars have encountered difficulties accessing data necessary for comprehending the factors prompting these transitions, which possess significant ramifications for federal expenditures on Medicare as well as individuals’ health outcomes.
Now, a fresh study in the June issue of Health Affairs uncovers what drives individuals to change Medicare Advantage plans or depart from MA entirely.
The struggle to access essential care, coupled with frustration regarding the quality of care received, plays a far more crucial role in shifting to another MA plan than the expenses incurred, the research indicates.
However, access problems are considerably more likely to compel someone to exit MA altogether and revert to traditional Medicare.
Dissatisfaction with accessibility was notably prevalent among individuals reporting poor health—a demographic shown in previous studies to exhibit the highest rates of MA plan changes and departures.
Geoffrey Hoffman, the primary author and associate professor at the U-M School of Nursing, states that the study reveals people enrolling in an MA plan with a low star rating—of which they might have been unaware unless they utilized Medicare’s Plan Finder—were also more inclined to switch.
“The concept of the private market for Medicare Advantage plans assumes consumers will shop around as their requirements shift, but in healthcare, you usually must experience it to determine whether you wish to change,” he explained. “We demonstrate that those remaining in MA are searching for improved service, while those transitioning to traditional Medicare are likely facing substantial health needs and are driven more by dissatisfaction with care accessibility issues within MA.”
The recent findings concerning individuals in poor health leaving for traditional Medicare corroborate studies by others, but from a patient-centered perspective rather than a billing-focused approach. This is due to Hoffman and colleagues employing anonymous data reflecting satisfaction with access, costs, and quality from surveys completed by Medicare beneficiaries each year, correlating it with anonymous enrollment data regarding MA.
The research also suggests that the star ratings system, which assigns one to five stars to each MA plan based on a mix of data including participant surveys, can serve as a reliable guide for consumers when selecting a plan.
“Although not flawless, the star rating a plan garners conveys something significant that our study indicates is closely tied to why individuals are opting to switch,” Hoffman noted.
He also observes that plan generosity—a metric not easily accessible to those selecting Medicare options—also forecasts switching behavior, with beneficiaries in more generous plans displaying a lower likelihood of switching.
Unhappy participants
The U-M study reveals that individuals who transitioned from their MA plan to any other Medicare option were significantly more likely than those remaining with their plan to report difficulties in obtaining necessary care and dissatisfaction with both the cost and quality of their care.
People reporting poor health were more than twice as likely as other MA enrollees to say they faced hurdles in accessing needed care, over three times as likely to express dissatisfaction with care quality, and more than twice as likely to be unhappy with the expenses associated with their care and specialty services. Approximately 15% of the study participants indicated being in poor health.
Nevertheless, overall dissatisfaction regarding expenses was not linked to departing from a MA plan. Accessibility and care quality concerns were, as well as enrollment in plans characterized by low star ratings and minimal benefit generosity.
Individuals facing challenges in accessing essential care demonstrated a higher tendency to switch from MA to traditional Medicare, which does not impose restrictions on the doctors and hospitals beneficiaries can visit. Costs appear to have a lesser influence on switching behavior given that, unlike traditional Medicare, MA plans impose caps on enrollees’ out-of-pocket expenses.
The transition of individuals with significant health requirements to traditional Medicare has substantial implications for how the government manages payments to the insurance companies that administer MA plans, as well as for the financial resources allocated to traditional Medicare itself. When higher-cost beneficiaries leave MA, traditional Medicare is left bearing the financial burden.
This also impacts beneficiaries’ out-of-pocket expenses, since only certain states permit individuals relocating from MA to receive unrestricted access to a Medigap plan that could supplement traditional Medicare.
In essence, individuals encountering serious health challenges who transition to traditional Medicare after being with MA may find themselves unable to qualify for Medigap coverage based on their state of residence. This situation implies that those exiting MA in favor of traditional Medicare might incur greater medical expenses without supplementary coverage to alleviate cost-sharing. Medigap plans are, moreover, offered by private insurance firms.
The study utilized Medicare Current Beneficiary Survey data correlated with anonymized information regarding 3,600 individuals whose surveys were analyzed; these surveys were conducted after the individuals had participated in their Medicare Advantage plan for no less than eight months. The researchers excluded information from some segments of older adults with unique circumstances, such as those eligible for Medicare due to low income or individuals enrolled in Medicare prior to age 65 due to disability or kidney failure.
The senior author of the study is Deborah Levine, a professor in the U-M Medical School’s Department of Internal Medicine in the Division of General Medicine. Other contributors include Lianlian Lei, Ishrat Alam, Myra Kim, Lillian Min, and Zhaohui Fan. Most authors are affiliated with the U-M Institute for Healthcare Policy and Innovation.
The study received funding from the National Institute on Aging within the National Institutes of Health (R01AG074944).