Sky High Initial Duals Opt-Out Rates: Is the Sky Falling or Just Not Clearing Yet?

By James Gutman - May 9, 2014 We knew the initial opt-out rates for beneficiaries auto-assigned to new plans to integrate care for Medicare-Medicaid dual eligibles would be high given the nature of the extremely vulnerable population targeted and the big changes envisioned for it. But this high? So high that a tabulation in Massachusetts shows as of April 1 a 1.54 ratio of opt-outs to enrollments? And so high that, as of the same date, 28.9% of the passively enrolled duals beneficiaries in the only California county (San Mateo) that has conducted large-scale passive enrollment so far have opted out? The opt-out rates are important not just because they will reduce the already scaled-down demos and thus their potential for large cost savings and improved clinical outcomes. They also are significant since they could alter the composition of the pool of beneficiaries to be managed, although opinions differ on whether those left in the demo will be sicker or less sick than those exercising their right not to participate. Perhaps equally significant is that the high opt-out rate could indicate provider problems either in the form, as Fallon Total Care head Richard Burke put it, of a poor “provider network match” between duals and the specialists they need and want, or deliberate efforts by providers to discourage their duals patients from enrolling in the demo. But it’s vital to keep in mind that there could be other less nefarious explanations for the high opt-out rates at the start. In Massachusetts, for instance, the initial notice of auto-assignment that eligible duals got came from the state, not the plans themselves, 60 days before the effective date and spelled out prominently what those beneficiaries needed to do if they didn’t want to participate. Duals anxious about changes in their health care may be likely to pull the plug right away, even though they also can opt out later, thus skewing the initial figures. There certainly, though, are reasons for concern regardless. Some patient-advocate groups in Massachusetts have been “agitated” about the demo there since many primary care physicians and the state’s largest hospital system are not in the networks, probably largely because of relatively low payment rates, noted Fallon Total Care Medical Director Dan Rome, M.D. The number of voluntary signups preceding auto-assignment has been way below expectations in that state, perhaps partly reflecting difficulties in contacting the duals population on a regular basis. What do you think are the main reasons for the high opt-out rates? How much of a reason for concern are they? Is CMS right in saying that this is a less significant cause for concern than if duals decided to leave the plans after they initially accepted enrollment? Are these figures mainly a result of state and federal regulators making sure duals preserved their rights not to participate, or are they more a clear sign of the difficulties ahead in applying managed care principles to a population unaccustomed to it? http://aishealth.com/blog/medicare-advantage-and-part-d/sky-high-initial-duals-opt-out-rates-sky-falling-or-just-not-clea?utm_source=Real%20Magnet&utm_medium=Email&utm_campaign=39721790