Seniors and disabled must enroll in managed care plans

By Al Norman

Beginning next January, the state of Massachusetts will require 105,000 low-income people to enroll in a managed care plan. If they do not pick a plan, the state will pick one for them. The federal government has blessed this concept, which has been a very controversial topic on Beacon Hill for years. The old “fee-for-service” model has fallen out of favor — because policy-makers say it encouraged doctors to order more and more tests. The incentive under fee for service was to get paid for tests, instead of good health outcomes.

This mandatory enrollment is euphemistically called “voluntary enrollment with an opt out” which means you will be enrolled in a plan whether you like it or not, and if you don’t like your plan, you can get out. In recent years, a proposal to force people into managed care plans was called “passive enrollment,” a term that is closer to the truth, but still somewhat indirect in its real meaning. But people understand what mandatory enrollment means — and that’s what they were afraid of.

For the past decade, advocates for the elderly and disabled have insisted that healthier consumers should not be forced to join managed care plans. There has been a long-standing concern that managed care means rationed care, and for the elderly and disabled who use more health care than younger populations, rationing is a scary word.

The managed care plan, which begins in six months, is called the Integrated Care Organization (ICO) plan, and it will be required for people age 21 to 64 who are dually eligible, meaning they are on Medicare and Medicaid. Their health care costs (based on 2008 numbers) is around $2.5 billion a year — half paid for by Medicaid, half paid for by Medicare. But it’s all public dollars.

Disability rights groups urged the Gov. Patrick administration not to force people to join ICOs. The plan itself, they argued, should attract members because its benefits would be better. But the administration — and the federal Centers for Medicare and Medicaid — decided that elders and the disabled should be enrolled in an ICO plan — and get themselves out of it if they did not like it. Most consumers, however, are not that aggressive and will stay put, not wanting to get into a fight with government officials.

The advocates said people should have choice — but the administration said their actuaries insisted that unless people were mass-enrolled into the ICO plan, it would fail, because only the sick would sign up, creating a very costly risk pool. In the end, the actuaries won out over the advocates — and the plan was submitted to the federal government with mandatory enrollment.

There was no media interest in this story, and advocates finally realized that mandatory enrollment was a “done deal,” including on Beacon Hill. This is in stark contrast to a similar managed care plan that was created about 10 years ago called the Senior Care Options (SCO) plan, which is just for people 65 and over.

The SCO plan was written into law as a voluntary enrollment plan. As of June, 2012, there were roughly 20,000 elders who voluntarily joined a SCO plan. The ICO plan will be five times larger, and if a dual eligible does not pick an ICO plan, they will be assigned one.

No doubt forcing people into managed care plans they did not pick will not be popular with seniors. Ironically, many duals might want to join an ICO plan because it will offer, in theory, better coordination of health and long term supports — because the plan covers not only doctor and hospital care, but home care and nursing facility care as well.

The ICO plan probably could have worked as a voluntary plan, as long as its benefit package was attractive. But that choice is now water over the managed care dam.