Among cost concerns was the admission by 42 percent of Medicaid managed care enrollees that they put off needed medical treatments because of cost.

July 31—Medicaid enrollees in a new survey indicated provider choice was the most important factor in their overall experience, and those in states with a dominant regional plan or one that owns a health system reported the easiest access to physicians and hospitals.

The J.D. Power 2017 Managed Medicaid Special Report surveyed 2,145 managed Medicaid health plan enrollees in 36 states and Washington, D.C., and noted that Medicaid enrollees—unlike the commercially insured—indicated provider choice was the most important factor of overall member experience.

“When it comes to what drives satisfaction with the plan, I think people would assume it’s cost, but it has far more to do with access to care, whether that be doctors, specialists, hospitals, urgent care, etc.,” said Valerie Monet, senior director of the health insurance practice of J.D. Power. “Provider network/access to care and perceptions related to coverage and benefits are the two most impactful aspects of the experience," she added, which comprise 50 percent of the total experience, compared with cost, which accounts for 16 percent.

That focus on provider access is generally because that is the one plan feature that federal and state laws and regulations allow Medicaid plans to vary, according to Kip Piper, who advises state Medicaid programs.

“The members have little experience with insurance markets and are not really buying their coverage, they are picking from among plans pre-selected by the state and funded by taxpayers,” Piper said. “So they look at what they already know, on what’s visible, and that is often their existing providers and the respected, visible players in the local health care delivery system.

The findings related to greater access for Medicaid enrollees in states with either a dominant regional plan or a health-system-owning plan underscored to the authors the importance of building robust networks and focusing on coordination of care between providers. The states rated by Medicaid enrollees as having the best access to hospitals and physicians were Iowa, Tennessee, Arizona, and Indiana.

Monet noted that fully integrated delivery systems comprised “a very small share of the total plans in the study."

“Generally speaking, health plans that own or are invested in healthcare delivery tend to provide a more highly satisfying experience,” Monet said. “They aren’t the only plans that do so. Some Blues with strong networks provide an equal—and sometimes better—experience in managing Medicaid member experiences.”

The good news for provider-sponsored plans followed a dour June report from the Robert Wood Johnson Foundation (RWJF) about the finances of such plans, which found most of the 42 health plans formed or acquired by providers since 2010 continue to operate at a loss, and six have failed.

The Obama administration’s massive 2016 Medicaid managed care rules and a substantial expansion of authority by the Centers for Medicare & Medicaid Services over states and plans may make it harder for the non-profit, provider-affiliated plans to compete, according to Piper.

“But at the same time, the concept of provider-led plans has gained traction in southern states--like North Carolina, Alabama, and Arkansas,” Piper said. 

For Monet, the big surprise in the survey findings was that health plans don’t always help Medicaid enrollees find the care they need or steer them toward more appropriate sites of care. For instance, she noted that only 32 percent of respondents said they found their physician through their plan.

“The rest are just going to a doctor they found near their home or workplace, getting recommendations from family and friends—or even a local clinic that may not accept their coverage, or going online to search out care themselves,” Monet said. “The counter-wisdom here is that more satisfied Medicaid recipients may actually turn out to be more engaged in their own health and in working with a provider, which might, in turn, drive down lifetime cost of care."

Indiana was notable because it featured the Healthy Indiana Plan (HIP), which is the only state program to require every recipient to contribute to a health savings account and has higher out-of-pocket expenditures than the national average. However, the Indiana program lacked any drop in cost satisfaction among recipients.

The survey results told Monet that Medicaid programs like Indiana’s—which may proliferate under pending waivers—need to engage the patients as consumers, listen to them, and engage them on their level to retain them as being active in their healthcare.

“[It] seems even more critical under HIP models—this is the new ‘norm,’” Monet said. “These new designs encourage the member to make smarter decisions with healthcare dollars, even under an entitlement program.”

On a 1,000-point scale, overall satisfaction with managed Medicaid plans averaged 784, which was 78 points more than the average commercial plan enrollee score.

A recent analysis of federal survey data found similarly high satisfaction with Medicaid by its enrollees. For instance, the study, published in July in JAMA Internal Medicine, found Medicaid enrollees gave their overall health care an average rating of 7.9 on a 10-point scale.

Such findings come as Republicans in Congress are considering changes to Medicaid financing and the Trump administration is encouraging more wide-ranging waiver applications from the states.

“The changes in Medicaid could create new opportunities for health insurers, including those that are provider-sponsored,” the RWJF authors noted.

Enrollee Confusion

The J.D. Power survey found that 62 percent of Medicaid plan enrollees don’t fully understand how their plan or coverage works.

“There is a significant gap in understanding what these plans cover and how to operate within the parameters of what the plan offers,” Monet said. “Given that, it’s not surprising that 68 percent of members say plans are covering all the services they’d expect.”

Monet said health plan communications are critical. She cited the use of in-person access points, mail, and digital communications for enrollees, as well as communications to providers about how to work with plan members as drivers of satisfaction and engagement to improve access.

Cost Concerns

Among the concerns was the admission by 42 percent of Medicaid managed care enrollees that they put off needed medical treatments because of cost. Similarly, 40 percent avoided buying prescription medications due to cost. More than half of some individual plan members were avoiding services due to cost.

“The perception that getting care will be too expensive is still a huge barrier for Medicaid members,” Monet said.

Federal law allows premium and cost sharing amounts for family members enrolled in Medicaid of up to 5 percent of household income. For children, 26 states charging monthly or quarterly premiums in Medicaid or CHIP, 39 states charge parents cost sharing in Medicaid, and 23 of the 31 states that have expanded Medicaid charge cost sharing for expansion adults, according to the Kaiser Family Foundation.

Other access problems included nearly one in four Medicaid enrollees who said they were denied coverage for a specialist or other provider to whom they were referred. Among such denied enrollees, 48 percent said they had to find a work-around such as visiting an emergency department or waiting until after 5 p.m. to avoid obtaining pre-authorizations for care.

Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Tuesday, August 01, 2017