For decades concerns have existed that Medicare Advantage plans were more interested in having healthy than unhealthy members. With the advent of the current risk score-based reimbursement methodology, many plans actually seem to seek unhealthy members on whom they can potentially make higher profits. Nothwithstanding this, people with serious chronic or acute illness may find being in a private health plan as opposed to fee-for-service Medicare too constraining due to network, prior authorization or other features of the plans. The Government Accounting Office looked at characteristics of people who disenrolled from Medicare Advantage plans. (GAO Report) GAO examined 126 contracts that higher than the median, which was 10.6%, disenrollment rates. Of these, under 35 contracts people in poor health were much more likely to disenroll than were beneficiaries in good health. But the reasons for disenrollment appear to have more to do with misunderstanding the nature of Medicare Advantage than any effort by the plans to have them disenroll. The main reason people in plans with disproportionate disenrollment of healthy members left was not having a preferred provider in the network, cited by over 40% of the disenrollees, followed by feeling like they weren’t getting care they needed, cited by over 25%. Network presence is available prior to enrollment, as are other restrictions on care access. Random care-seeking is a source of lack of care coordination and MA plans do a demonstrably better job of coordinating and managing care and producing better outcomes. So it is not necessarily in the beneficiary’s best interest to disenroll.
In contrast, disenrollment from plans without a high proportion of unhealthy disenrollees was more linked to cost of care concerns and to issues related to drug information and coverage. GAO noted that CMS does not necessarily track the health status of disenrollees and recommended that it do so to see if plans are pushing them out in someway. Since it is highly likely that the real issue is beneficiary failure to understand the nature of MA plans, and patients with serious chronic illnesses may be less capable of such understanding, a better fix would be to ensure that beneficiaries get clear information about provider network composition and limits on care access, and that they acknowledge that they have received and understand this information. Given current reimbursement structures, it seems very unlikely that plans are trying to get unhealthy members out. It also would often be better for these beneficiaries to remain in a managed environment in which their care is more closely monitored than to be in the uncoordinated traditional Medicare program.