Higher-than-expected enrollment has challenged the budget and the administration of public health coverage in Massachusetts ever since its universal health plan took effect in April 2006. Christina Severin, executive director of Network Health in Medford, Mass., a private plan that covers subsidized Commonwealth Care members as well as MassHealth Medicaid members, believes programs will continue to struggle until one particular problem is solved: enrollment churning.
"We looked at 88,000 of our MassHealth members," she says. "Fifty-eight percent were disenrolled annually. Of those, 47% re-enrolled within 30 days. Of all those who re-enrolled, 70% did so within 90 days."
Often members miss re-enrollment because reminders and materials do not reach them, Severin says. She believes churning might be reduced if the challenging re-enrollment process itself were simpler for members and took into account the fact that people receiving public assistance are difficult to reach. For example, only 25% of Network Health members' phone numbers are reliable.
Senior Director of Marketing Deborah Gordon says the plan makes multiple attempts to reach individual members by mail and phone to remind them to re-enroll. On an aggregate basis, the plan initiates approximately 500,000 contacts per year, Gordon says.
Some states have started to lean toward presumptive coverage continuation in public coverage programs, reducing re-enrollment processes, according to Laura Summer, senior research scholar at Georgetown University's Health Policy Institute. Louisiana program officials, for example, conduct internal member-eligibility reviews with available information from other programs or state databases. Members found eligible in that process are re-enrolled. The method has dramatically reduced the number of children who lose coverage at renewal and has reduced administrative costs as well.
"It's certainly to states' advantage from the perspective of administrative costs to curtail churning because every time they have to disenroll then re-enroll a person, then potentially assign a person to a health plan and get them enrolled there again, it is costly. And states certainly have limited resources," Summer says.
Presumptive disenrollment is a logical approach to ensure only those who qualify receive coverage, however, Severin believes Massachusetts must find middle ground between the hard-line policy that drops eligible members and a free-handed approach that might open up the system to abuse.
"We certainly share the state's values of not wanting people enrolled in Medicaid who don't meet the current eligibility criteria," she says. "At the same time, we feel that the data supports the fact that those who are disenrolled are disproportionately people who are eligible."
While Network Health has a longer history of tracking churn with its Medicaid members, it now sees similar churn cropping up in the new Commonwealth Care subsidized program. In March, the subsidized plan had 5,100 enrollments and 6,200 disenrollments, for a net loss of 1,100 members, Gordon says.
"People like to talk about administrative waste and like to point the finger at health plans," Severin says. "But this is where the health plan is saying we have an opportunity to decrease administrative inefficiencies."
Solutions have not come easily, however.
In 2004, Network Health worked with the state to create a one-page, simplified redetermination form that the plan could fax to the state office. In piloting the shorter form, Network Health found that more members were able to continue coverage seamlessly compared to members who had to complete the standard eight-page process. According to Gordon, state personnel processing the incoming data could not keep pace with the volume of faxed re-enrollments, and Network Health was instructed to stop using the simplified form immediately.