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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Regular listeners of our Humble podcast know that we love to learn about and talk about Medicare Advantage at Health Affairs. Medicare Advantage now covers more Medicare beneficiaries than traditional Medicare. And with such rapid growth and transformation come tremendous opportunities for important research on what kind of MA plans are good at covering people. Even so, such trends can be difficult to measure. How can we tell which plans are actually meeting beneficiaries' needs more effectively than others?
Rob Lott:Such questions are tough to answer, of course, but that won't stop us from slowly and steadily inching, in that direction, and it's the subject of today's health podocy. I'm here today with Em Balkan, a PhD candidate in health services policy and practice at Brown University. Together with coauthors, they have a new article in the March issue of Health Affairs, and its title is also one of its main findings. Rapid disenrollment rates tripled for Medicare Advantage beneficiaries from 2017 to 2022. This is a really interesting article, and I can't wait to dig in on it.
Rob Lott:Em Balkan, welcome to A Health Podyssey.
Em Balkan:Thank you so much. So happy to be here.
Rob Lott:And a quick programming note for our listeners before we dive in, I just wanna remind folks that we're now recording video in addition to audio. So in addition to your regular, podcast, platform, you can also check us out on YouTube. Let us know what you think. All right, Em, let's dive right in and maybe start with some background. I think maybe it could be useful if you can sort of remind us when Medicare beneficiaries typically enroll in an MA plan And when can they disenroll?
Rob Lott:It's sort of a basic question, but I think a good starting point for us today.
Em Balkan:Yeah, it's seemingly a very basic question, but Medicare enrollment can get so complicated. So I'm glad that we're covering this to start. It's a great question. So anyone with Medicare, they can choose to either have traditional Medicare provided through the federal government, that classic red, white, and blue card. And generally, those folks will also have like a standalone drug plan.
Em Balkan:Or as you mentioned, more and more people in the majority of people with Medicare have a Medicare Advantage plan, which is a private plan that provides typically all of someone's medical benefits, including their drug coverage. So when people are first eligible for Medicare, they have an initial coverage period or an initial election period where they can choose whether or not they want an MA plan at that time. And sometimes people are still working and maybe have active employer insurance. And when they decide to go on to Medicare, they have that initial period as well. So outside of that period, all Medicare beneficiaries can also choose to either change their plan, choose a new plan annually during the open enrollment period, which is sometimes referred to as fall open enrollment.
Em Balkan:And this occurs every year, October 15 to December 7. And anyone who makes a change during that time, they have new coverage effective that January, the following January. And outside of this period, there is also a Medicare Advantage open enrollment period, which in recent years, it is from January through March of every year. And during that time period, anyone with a Medicare Advantage plan, they can either choose to disenroll and enroll into traditional Medicare or to choose a different Medicare Advantage plan. Finally, there's, like I said, it's a great question.
Em Balkan:So outside of these specific election periods, sometimes people can also make changes, but only if they're eligible for what's called a special enrollment period. A common, like, special enrollment period that a lot of people are familiar with is the one for those who have Medicare and Medicaid or other benefits for folks with lower incomes, namely the Medicare Savings Program or the Low Income Subsidy, otherwise known as Extra Help. And for many years, like historically, people with those benefits, they can change their plan any month they want. But starting this year, CMS changed that a bit. So it's not as liberal as it used to be.
Em Balkan:And then there's other special enrollment periods that people can qualify for as well. And there's a pretty hefty list of those. But yeah, so it's the initial election period, open enrollment, and then the Medicare Advantage open enrollment, and then those special periods.
Rob Lott:Great. Well, I want to go to one more seemingly basic, but I'm sure not quite as simple as one might suspect question, and that is why might someone disenroll quickly? I know this is the subject of your paper. Why would someone disenroll so quickly after having just signed up?
Em Balkan:It is a really great question, and this topic is actually very understudied. Our study was the first to examine what we call rapid disenrollment. So when we say rapid disenrollment, what we mean is when a person disenrolls from a newly elected Medicare Advantage plan within the first three months that they have it, so between January and March. So they elect a new plan, it's effective January 1, and by April 1, they're no longer in that plan. And the trends that we examine, they capture all the instances of rapid disenrollment, although we do not know for sure the exact reasons for each person's decision to rapidly disenroll.
Em Balkan:That being said, you know, what I think is rapid disenrollment could indicate that a person is dissatisfied with their healthcare experiences or with their plan benefits. And as I mentioned, you know, people, when they have Medicare Advantage, it generally covers all of their health care. And Medicare Advantage plans, their benefit designs vary and they can vary pretty widely. So depending on what what plan a person has, their cost sharing can look different. So that means like they have a different copay level.
Em Balkan:They have a deductible. They also the Medicare Advantage plans will also have different provider networks. So whether or not they can continue seeing their providers dependent upon their plan's network, each plan also has different, they'll have different drug formularies. They'll have different supplemental benefits like vision and transportation. And so you get the picture, it's a very wide array of different plans and situations that somebody can find themselves in.
Em Balkan:And on top of all of that, the MA plan market for many beneficiaries is pretty vast. And there's a lot of talk about MA right now. You know, the market is changing, but during our study period from 2017 to 2022, there was an increasing amount of plans that the average beneficiary could choose from. So for example, data documented by KFF shows that in 2022, which is the last year of our study period, beneficiaries had on average 38 different plans to choose from. So they have 38 different plans to choose from.
Em Balkan:They each can have different benefit designs and it can get really dizzying and complicated. And earlier in my career, I actually like would counsel people about their plan options. And so I'm sure anyone else in this situation, whether they're a Medicare beneficiary or someone who's helped somebody enroll, they can relate to this process being pretty tedious. And so given all of this, I think it's pretty easy to imagine that somebody might enroll into a plan thinking it's one thing and then realizing, oh, my drug isn't covered or my provider that I thought was in network isn't in network. And related to this too, there is a fantastic paper actually recently published in Health Affairs as well by Grace McElbee and co authors that looked at people who were using the enrollment periods that we're talking about.
Em Balkan:And that paper found that people who switched plans outside of fall open enrollment, so outside of that fall open enrollment period, they tended to have higher risk scores and hospitalization rates before they were switching compared to those who did switch during that standard time. And they also found that beneficiaries who decided to go from their Medicare Advantage plan to either traditional Medicare or to a Medicare Advantage plan that had a bigger network of providers, those folks also tend to have higher risk scores and hospitalization rates. And so in theory, I can also imagine that in the first three months of a year, somebody who thought that their health was going to look a certain way, like their healthcare needs were going to look a certain way, if they get a new diagnosis, if they're hospitalized and all of a sudden they have a different level of need, as this paper found, those folks are more often likely to switch throughout the year instead of just in the fall.
Rob Lott:Got it. Alright. Well, wonderful context. In just a second, I wanna ask you about the findings of your paper, but first, let's take a quick Yeah. And we're back.
Rob Lott:I'm here with Em Balkan, talking about their paper in, the March issue of Health Affairs on rapid disenrollment rates for Medicare Advantage beneficiaries from 2017 to 2022. As we said, the title of your papers indicates that it tripled. So I'd love you to just dive right into some of your findings and tell us what we can take away from it.
Em Balkan:Sure, yeah, thank you. So our paper had three key findings. The first is in the title and as you just said, so there was an overall increase in rapid disenrollment. And And in so 2017, the first year of our study period, three point five percent of people that had a newly elected MA plan that January, by that April, they had already disenrolled. So it was three point five percent in 2017.
Em Balkan:By 2022, that number was twelve point two percent. And over the same time period, in our paper, we have a graphic or a figure that looks at this rate over time compared to the rate of people who were switching during Medicare open enrollment period in the fall. And that number was relatively stable over the same amount of time. And interestingly, by 2022, we saw that about a quarter of people that had a new Medicare Advantage plan as of January 2022, they were disenrolled from that plan within, you know, by that time the following year. So we had two other main findings, the first being that enrollees with both Medicare and Medicaid commonly referred to as dual eligible people or dually enrolled people, so they had higher proportions of rapid disenrollment when we compare them to folks who have Medicare only, so who don't have Medicaid.
Em Balkan:So as I mentioned, the overall rapid disenrollment rate in 2022 was twelve point two percent. For those with both Medicare and Medicaid, it was nineteen point four percent. So almost twenty percent of people that have both Medicare and Medicaid, if they had a new plan as of January, they were in a different plan or they were in traditional Medicare as of that April. And when we look at folks who don't have Medicaid, who have Medicare only, only ten percent, well, not only, still a lot of people, but about half, so ten percent of people with Medicare only were rapidly disenrolled from their plan in 2022. And so this theme was also seen in different ways as well.
Em Balkan:Insurance companies that had higher proportions of people with Medicare and Medicaid, they had higher rates of rapid disenrollment. MA plans specifically designed for people with Medicare and Medicaid, commonly referred to as dual SNPs or dual special needs plans, they also had higher rates of rapid disenrollment when compared to standard MA plans. And finally, our third finding is that when we look at folks by race and ethnicity or the race and ethnicity variable in the Medicare data, we found that there were higher proportions of Black, Hispanic, and American Indian and Alaska Native enrollees who rapidly disenrolled when compared to White and Asian Pacific Islander enrollees. And this was true across Medicaid enrollment statuses. So whether or not somebody had Medicare or Medicaid, we found that this was true.
Em Balkan:And prior research has found that Black and Hispanic beneficiaries are more likely to enroll in Medicare Advantage as well as lower quality plans. And so obviously this and our other findings are very interesting and warrant further study and indicate potentially concerning trends. And so we had a few different ideas for future research and suggestions that we included in the paper, and I'd be happy to talk more about.
Rob Lott:Great. Yeah. I want to come come back to those for sure before we wrap up. Before we get there, can you say a little bit about sort of the larger debate? Obviously, some proponents see the competitive forces of MA as an important tool to drive innovation.
Rob Lott:Others see it as sort of selling out a once public program to the private sector, with taxpayers sort of bearing that cost. What evidence or perhaps what questions do you take from these findings when thinking about that broader debate?
Em Balkan:Yeah. It's a really great question. You know, we could probably spend hours talking talking about all the nuances of this. As you pointed out, I feel like right now too, it's like kind of, you know, as someone who's been like a Medicare Advantage nerd for a long time, like I feel like there's so much literature and discussion around MA right now, which is, I think it's great. And I'm hopeful that maybe there'll be some good changes that can take place.
Em Balkan:And you're right. So our paper, I think, does complement a lot of these discussions nicely. For example, as I mentioned, that recent piece in Health Affairs by Grace and her co authors, that complements a lot of evidence we already have that shows that people that have higher medical needs, they tend to avoid Medicare Advantage. And I think that that's something that we really need to look into. In their paper, they also found that compared to those who switched during the Medicare open enrollment period, those who switched during the Medicare Advantage open enrollment period, so during the same time that we're talking about with rapid disenrollment or people that use the special enrollment period, they were more likely to be black or Hispanic.
Em Balkan:And on average, they resided in areas with modestly higher socioeconomic deprivation. So given all of this, I also view my work and I think it's important to view public health work with a racial equity lens. And so I think that future research and in this larger debate, we need to think about who is MA serving and who could it be serving better? And so if we're seeing that higher proportions of black and Hispanic folks of people with Medicaid or who are lower income are leaving Medicare Advantage, like the plans that they're initially enrolled in are leaving them more quickly, what does that say? And what can we do about that?
Em Balkan:I think it's something that's really important to think about. Especially, there's so many reasons for this. And one of them being actually my co authors recently published a paper that was also in health affairs. I think it came out last year. They found that Medicare Advantage Networks included few black or Hispanic physicians, which makes concordant care inaccessible for many people.
Em Balkan:So there's so many layers to this. And like I said, we can probably talk about it for a long time, But a few other things that I wanted to, that are top of mind too, is the role of brokers. And so there was a lawsuit last year that kind of brought to light the role of brokers. And so millions of people with Medicare use brokers to enroll into Medicare Advantage, and there isn't much evidence out about this. And fortunately, my team is starting to actually work on some studies that look at the role of brokers with Medicare Advantage enrollment.
Em Balkan:And so this is something that I'm glad that we're looking at and looking into. And this also kind of all ties into a lot of the discussions around Medicare Advantage funding and the idea that duals or people with Medicare and Medicaid are more likely to rapid disenroll. And we also know that people with Medicare and Medicaid, that Medicare advantage plans have a higher per member per month rate for people with Medicare and Medicaid. These are all things that could definitely be teased out. And there's a lot that we can keep looking into.
Em Balkan:And so, yeah, I think I have more questions than answers right now when it comes to these sorts of questions. Like I said, I am glad to see more
Rob Lott:and
Em Balkan:more attention to this. In fact, there was a really fantastic recent piece, and I think it was JAMA by Mark Meselbach and colleagues, and an accompanying editorial by Hannah James that talks about this changing MA landscape because we're seeing MA plans exiting the market. And I think that those pieces and others are asking all of these questions too. And so it'll be great to see as more papers and studies come out and more discussions are happening, what the next steps will be for a Medicare Advantage.
Rob Lott:Great. Well, Em Balkan, thank you so much for taking the time to chat with us. Thank you for your work on this paper. Really fascinating stuff, and really appreciate you being here to tell us about it today.
Em Balkan:Thank you. Thank you so much. This was this was great. Thank you.
Rob Lott:Absolutely. And to our listeners, thanks for tuning in. If you enjoyed this episode, share it with a friend, leave a review, subscribe, and, of course, tune in next week. Thanks, everyone.