Complex Medicaid system is unclear to beneficiaries

As Medicaid’s involvement with managed care becomes more pervasive, the system becomes more unwieldy. Patients often have little idea of their options of care, many are excluded or exempt from mandatory enrollment, and programs change their policies as often as they tear pages from the calendar. The result is often a distrust of the system by the people the system was created to help.

"Everything is under pressure — pressure to get started, pressure to get people enrolled," Chris Molnar tells State Health Watch. "It’s rare that you get evaluation efforts. There is no replication of successes within the system." Ms. Molnar is one of the authors of Educating Medicaid Beneficiaries About Managed Care: Approaches in 13 Cities. She is a researcher with the Community Service Society of New York in New York City.

The study of 13 cities does note some successes, but it mainly tells a tale of a varied set of interpretations of what is good for Medicaid patients who sign up for care. The cites studied were Chicago; Detroit; the District of Columbia; Houston; Los Angeles; Memphis, TN; Miami; Newark, NJ; New York City; Philadelphia; Phoenix; Portland, OR; and Seattle. The research was sponsored by The Commonwealth Fund in New York City.

"The most exciting place was Seattle. It had a good infrastructure; it had real-time data about health plans; and its health provider was on-line," adds Ms. Molnar. "It had a healthy kids program that subcontracts with county health departments. [The city] got money down to the community level for its outreach program; it reproduced information that was multilingual and multiethnic."

At the other end of the spectrum, according to Ms. Molnar, was Memphis, where one agency simply sent out a list of managed care plans for potential recipients to choose from. Overall, in all 13 test cities, once a Medicaid recipient signed up for a managed care plan, education about options came to a variety of halts. More emphasis on educating recipients tends to come when managed care plans are new because there is more of a political will to put money into the transition, she explains.

Ideally, managed care heads off rising costs by eliminating specialty and acute hospital care and replacing them with primary and preventive care. But to make competition among managed care companies a reality — to hold down costs — Medicaid beneficiaries need to know how to make the best decisions for themselves. Beneficiaries must know how to choose the right plan, how to work their way through the managed care system, and how to avoid getting sick in the first place. But the system as administered through the 13 test cities has fostered a distrust of the system, and beneficiaries don’t get the full benefit that is intended.

The cities that were studied had a variety of approaches designed to bring beneficiaries into the fold. Mailings, telephone banks, public awareness campaigns, and outreach efforts via community-based organizations are examples, and none seem to work as well as intended. "We don’t know what works," a broker representative said in the study.

The study concluded all 13 cities had basically the same weaknesses, and many of their problems could be solved. The main weaknesses, according to the study, were:

• a failure to tailor outreach programs to the specific educational needs of the Medicaid population;

• poor quality information about providers and plans;

• an inability to monitor program performance on educational objectives;

• reliance on a single intervention to convey information about such a complex set of topics.

One solution, suggested in the study, is that Medicaid programs should tailor their educational messages to meet the needs of beneficiaries. Few programs in the cities studied sought educational expertise or advice in developing enrollment materials or outreach strategies. As a result, education materials don’t suit the needs of Medicaid beneficiaries.

"In New York and Los Angeles, they are contractually required to provide beneficiaries with a certain amount of information," Ms. Molnar says. "They give out a packet explaining the program, then five weeks later more information follows. There are multiple reminder letters. All that is sort of difficult to get through. I heard it time and time again from beneficiaries, I got that information, and I threw it out. I couldn’t handle it.’ Sometimes, the information packets were the size of phone books."

The study also recommended that Medicaid programs develop up-to-date provider databases and provide appropriate plan-specific information. None of the 13 cities studied had a satisfactory way to make this information available. Distributing provider directories is expensive and inefficient, too, according to the study. Many managed care companies share the opinion that beneficiaries are not capable of understanding quality measures and comparative information about consumer satisfaction, the study noted, but that is exactly the information that beneficiaries are interested in. Much of the problem is the language used — too much jargon and many technical terms never become translated to everyday, understandable language for beneficiaries.

"The challenge that states and counties face is that lawyers say this and that must be in the material, and the education people are the ones who say, You’ve got to be kidding,’" Ms. Molnar says. "In New York, there is an effort to make sure the information about the program is written at the fourth-grade reading level. There is white space, big print, and pictures. On the other hand, there is a tremendous number of technical terms and jargon. Couldn’t it be simplified?

"In programs like these, where there are public purchasers and there is no employer as an intermediary, people say, How do I get through this? Help me wade through this material.’ These are the most vulnerable and least prepared beneficiaries."

It’s not just the English language that presents problems. Reaching non-English-8

speaking beneficiaries has its own challenges. The study found that basic Medicaid terms, such as primary care provider, primary care doctor, personal doctor, and primary care practitioner, had no equivalents in Spanish, Chinese, or Cambodian.

Medicaid programs need to develop tools to determine how effective educational efforts are, the study concluded. Many programs put the cart in front of the horse by conducting studies of their material, and they come up with a tremendous amount of information. But most state officials interviewed said they still don’t understand how to properly reach beneficiaries.

"We visited places where there were voluminous data collected. In California, they had massive piles of information and providers were saying, It’s taking time away from my work.’ There is so much information being captured, but no one knows how to use the system," Ms. Molnar says.

Many state officials and broker staff contend that outreach through existing community-based organizations is a viable avenue to communication. Local groups know the communities better than the state does, one former state administrator admitted in the study. In Houston, Detroit, Los Angeles, and New York City, the broker subcontracts with community-based organizations for outreach and education. Others, such as Philadelphia, Miami, and Phoenix, use such organizations to present information to groups.

The study also concluded that Medicaid managed care education should be ongoing — extending much further than the initial signing up of beneficiaries. "Most brokers and states acknowledge the need for continual education, but no one knows who will pay for it." Plus, half the patients enrolled in Medicaid are in the program for less than a year, so the urgency to continue education on the program withers steadily. In Chicago, the District of Columbia, Houston, Los Angeles, Newark, Philadelphia, and Portland, the providers no longer use marketplace incentives to get the plans to educate beneficiaries.

The strategy now is to have providers create a comprehensive health education program.

"What is needed is a series of clear and focused messages tailored to the needs of Medicaid beneficiaries and delivered through multiple approaches and settings — all of which are periodically and systematically evaluated," the study said.