Analysis of Drivers of Disenrollment and Plan Switching Among Medicare Advantage Beneficiaries

Abstract

IMPORTANCE How often enrollees with complex care needs leave the Medicare Advantage (MA) program and what might drive their decisions remain unknown. OBJECTIVE To characterize trends in switching to and from MA among high-need beneficiaries and to evaluate the drivers of disenrollment decisions. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of MA and traditional Medicare (TM) enrollees from January 1, 2014, through December 31, 2015, used a multinomial logit regression stratified by Medicare-Medicaid eligibility status. All 14 589 645 non-high-need MA enrollees and 1302 470 high-need enrollees in the United States who survived until the end of 2014 were eligible for the analysis. Data were analyzed from November 1, 2017, through August 1, 2018. EXPOSURES Enrollee dual eligibility and high-need status (based on complex chronic conditions, multiple morbidities, use of health care services, functional impairment, and frailty indicators), MA plan star rating, and cost sharing. MAIN OUTCOMES AND MEASURES The proportion of enrollees who disenrolled into TM, remained in the same MA plan, or who switched plans within the MA program. RESULTS A total of 13 901 816 enrollees were included in the analysis (56.2% women; mean [SD] age, 70.9 [9.9] years). Among the 1302 470 high-need enrollees, an adjusted 4.6% (95% CI, 4.5%-4.6%) of Medicare-only and 14.8% (95% CI, 14.5%-15.0%) of Medicare-Medicaid members switched from MA to TM compared with 3.3% (95% CI, 3.3%-3.3%) and 4.6% (95% CI, 4.5%-4.7%), respectively, among non-high-need enrollees. Among enrollees in low-quality plans, 23.0% (95% CI, 22.3%-23.9%) of Medicare and 42.8% (95% CI, 40.5%-45.1%) of dual-eligible high-need enrollees left MA. Even in high-quality plans, high-need members disenrolled at higher rates than non-high-need members (4.9% [95% CI, 4.6%-5.2%] vs 1.8% [95% CI, 1.8%-1.9%] for Medicare-only enrollees and 11.3% vs 2.4% dual eligible enrollees). Enrollment in a 5.0-star rated plan was associated with a 30.1-percentage point reduction (95% CI, −31.7 to −28.4 percentage points) in the probability of disenrollment among high-need individuals. A $100 increase in monthly premiums was associated with a 33.9–percentage point increase (95% CI, −34.9 to −33.0 percentage points) in the likelihood of switching plans, and a small reduction in the likelihood of disenrolling (−2.7 percentage points; 95% CI, −3.2 to −2.2 percentage points). Among Medicare-Medicaid eligible participants, 14.1% (95% CI, 14.0%-14.2%) of high-need and 16.7% (95% CI, 16.6%-16.7%) of non-high-need enrollees switched from TM to MA. CONCLUSIONS AND RELEVANCE Results of this study suggest that substantially higher disenrollment from MA plans occurs among high-need and Medicare-Medicaid eligible enrollees. This study’s findings suggest that star ratings have the strongest association with disenrollment trends, whereas increases in monthly premiums are associated with greater likelihood of switching plans.

Health Care Utilization, Care Satisfaction, and Health Status for Medicare Advantage and Traditional Medicare Beneficiaries With and Without Alzheimer Disease and Related Dementias

“…Previous research [25][26][27][28] has found that healthy beneficiaries are more likely to enroll in MA than TM, suggesting that advantageous selection would invalidate a direct comparison between MA and TM beneficiaries. To address selection bias, we used an instrumental variable approach, using county-level MA enrollment rate as an instrument for the individual-level decision to enroll in MA plans.…”

Comparison of the Quality of Hospitals That Admit Medicare Advantage Patients vs Traditional Medicare Patients

“…Furthermore, MA and TM enrollees are known to differ in important ways 12 and may have different preferences when selecting which hospitals they use for their care needs.…”

Association of daily copayments with use of hospital care among medicare advantage enrollees

“…Most Medigap policies eliminate inpatient cost sharing altogether, which is a much larger change than our study and presumably less relevant for Medicare Advantage, purchasing Medigap reduces or eliminates cost sharing for many other services besides inpatient care, and the effect of cost sharing may differ in Medicare Advantage given supply-side, managed care constraints that are not found in traditional Medicare. Recent studies related to Medicare and Medicare Advantage focused on prescription drug use and adherence [12,13], skilled nursing facility utilization [14], or Medicare Advantage enrollment [15]. The lack of inpatient utilization studies in the broader Medicare fee-for-service and Medicare Advantage programs is an important gap since hospital costs are the largest component of Medicare spending and the Medicare Part A deductible is the largest single out-of-pocket expense in the traditional Medicare benefit structure, $1340 in 2018 [16].…”