What’s Behind High Opt-Out Rate Among Dual Eligibles in L.A. County?

The state’s duals demonstration project has hit a rough patch in Los Angeles County.

Health officials are in the middle of an effort to enroll a large segment of the state’s dual-eligible population in Cal MediConnect — a seven-county pilot project designed to coordinate care and funding for about 430,000 Californians who qualify for both Medi-Cal and Medicare.  

Los Angeles County has the state’s highest number of dual eligibles. State officials hope to get about 200,000 — or roughly half the pilot project’s total targeted enrollment — signed up in Cal MediConnect. But people in that county are staying away from the project in droves.

In the state’s October tally, the Los Angeles opt-out rate hit 50%, and last month it dipped slightly to 40%. Those rates are significantly higher than the statewide average of about 29% in the other participating counties.

The Los Angeles opt-out rate may actually grow larger, said Amber Cutler, staff attorney at the Los Angeles office of the National Senior Citizens Law Center.

“I think we’re going to see even higher numbers than that,” Cutler said. “Right now, they’re high everywhere, it’s not just in L.A. County. But I think we’ll see them go higher.”

Cutler said there are many possible reasons, including the enrollment method itself, which automatically signs people up for Cal MediConnect if eligible participants do nothing.

“Passive enrollment in general creates greater likelihood of opting out,” Cutler said. “But we’re not entirely sure what’s causing it in L.A. County.”

State and federal health officials have been analyzing the data and hope to come up with some answers to explain why so many more people in Los Angeles County have been rejecting enrollment. There are a number of theories.

Organized Effort To Opt Out?

One possibility is that an organized campaign has been mounted to urge dual eligibles to back out of participation.

There’s not much evidence of an organized effort, according to Martha Smith, chief duals program officer for Health Net. But that doesn’t rule out the idea that some dual eligibles are being advised to opt out by health professionals, she said.

“We are undertaking an in-depth analysis to make sure we understand the reasons why people are opting out, are there certain drivers that are getting them to opt out,” Smith said.

“But quite frankly, there is a certain emphasis in the provider community,” she said. “My sense of it is, it’s more a function of individual providers who are interested in protecting their fee-for-service Medicare base.”

According to Howard Kahn — CEO of L.A. Care Health Plan, one of the country’s largest Medicaid managed care companies — there are a greater number of those kinds of independent providers in Los Angeles County than in other participating counties.

“When we saw the 50% number, I was somewhat surprised by that,” Kahn said, “but really, to see the 40% number in the early stages, we thought it might go that way, particularly early on.”

Because providers have been able to bill Medicare on a fee-for-service basis to treat dual eligibles (also known as Medi-Medis), some are resistant to different payment systems, Kahn said.

“For a lot of physicians, Medi-Medis are a primary source of revenue,” Kahn said. “So any change is going to be greeted with concern. Lots of physicians who participate in managed care, they’re used to seeing how it works. But for providers in fee-for-service [systems], I think they’re worried about that.”

Other Factors at Play in L.A. County

Kahn, who will step down as CEO of L.A. Care next month, said there are a few aspects of Los Angeles County that differ greatly from other counties.

“Part of the issue is L.A. is just so large,” Kahn said. “When you look at the sheer numbers of providers and patients in the county, it’s huge. It’s the size of other states.”

That makes communication between state officials, health plans, providers and patients much more difficult — so a cohesive message is difficult to deliver, he said.

“It’s not just bigger, it’s bigger and more complicated,” Kahn said. “There are massive numbers of physicians not necessarily affiliated with large medical groups. In some other places, you have a couple of dominant medical groups and hospital chains. But in L.A., it’s not a consolidated market.”

Kahn, who formerly ran the Health Plan of San Mateo, said the difference between the two counties is striking.

“In San Mateo, I knew every primary care provider in the program,” Kahn said. “If I needed to contact anyone, I’d call them. In a smaller medical community, you can communicate with people much more directly.”

He said the communication challenge in L.A. extends beyond the providers: “Duals are either aged or disabled, so they need high levels of personal contact,” Kahn said. “This is a big environment in L.A.”

Smith said another factor that makes Los Angeles a unique county is its diversity of ethnicity and languages. When people have difficulty understanding, they could be more apt to opt out, she said.

“People are geographically dispersed, and it’s just so diverse,” she said.

If Some Opt Out, Will More Disenroll?

Cutler, the attorney with the NSCLC, said the opt-outs might only be the beginning.

“I think we will start to see the percentage of disenrollment rise, too,” Cutler said, “and that will be very important.”

Cal MediConnect is a voluntary program and eligible participants are free to opt in or opt out at any time. Because the passive enrollment approach results in many tens of thousands of duals suddenly discovering they’re enrolled in Cal MediConnect, the program could lose a lot of those people to disenrollment, Cutler said.

“The idea of passive enrollment is that people get these notices and don’t read them or understand them and, boom, they’re enrolled,” Cutler said.

But when those enrollees go to the pharmacy or to their provider and find that they’re in a different network, their initial response could be to undo that automatic enrollment, she said.

“If you get a notice that you’re being automatically enrolled into something and you don’t know what it is, the first thing you’ll do is disenroll,” Cutler said. “Passive enrollment undermines choice, and when you have passive enrollment it makes it feel less person-centered, less like it’s something good to choose, and ultimately you’re going to get a lot of people not wanting to do that. People don’t like being told what’s better for them.”

Data on disenrollment should start coming out by next month, Cutler said.

“Opt-outs are one thing, but I’m more concerned over the disenrollment rate,” Cutler said. “That would show a lag or lack of continuity of care, and that’s the most problematic to me, because passive enrollment feeds right into that.”

Better Care Coordination, Services

Cutler and other advocates have been critical of passive enrollment but have supported the idea of better care coordination through Cal MediConnect.  

Kahn said the high number of opt-outs is concerning on several levels — but his primary worry, he said, is that this is a chance to address the needs of a difficult and frail population.

“The Medi-Medis have very complex medical and social supports, and this is the first opportunity we’ve had to coordinate all the services under Medi-Cal managed care to improve their health,” Kahn said.

“Coordination and simplification and the monitoring and oversight of quality is critical,” he said. “In the end, it’s about the quality of life and care delivered, and care and services should lead to that.”

That was the sentiment voiced by Smith of Health Net, as well.

“Our overarching concern about all of this is it’s depriving this population of better, more integrated care,” Smith said. “Once people get into the program and understand the support they’re getting, they’ve been pleased.”

Kahn said the key to lowering the opt-out and disenrollment rates in Los Angeles County is communication — with individual providers, provider groups and dual eligibles.

“What we’re trying to do is simplify the message,” Kahn said.

State officials did not have a time frame for analyzing the data from Los Angeles County, but health plan officials hope some preliminary results will be available in the coming months.

Related Topics

Insight Medi-Cal Medicare