Research explores patient experience of North Carolina's Medicaid transition

In 2021, 1.6 million Medicaid beneficiaries in North Carolina moved from a fee-for-service Medicaid model to a managed care system known as N.C. Medicaid Managed Care. In this plan, the state pays a set amount per beneficiary each month to the private plan, and then the plan pays for any health care services received by the beneficiary.

"With such a major change affecting a vulnerable population, there was concern about enrollee awareness and engagement in the transition to the new private plans and continuity of care with their providers," said Amresh Hanchate, Ph.D., professor of social sciences and health policy at Wake Forest University School of Medicine.

The study findings may inform the implementation of future policy changes, including North Carolina's Medicaid expansion.

What impact did the transition have on Medicaid enrollees who live in Forsyth County?

To answer that question, researchers at Wake Forest University School of Medicine analyzed data from surveys and health medical records of Medicaid enrollees receiving primary care within the Atrium Health Wake Forest Baptist network, the largest provider network in western North Carolina.

One of the main findings was that a large proportion of enrollees were not aware of the transition process and were not engaged in the choice of plans.

"We were surprised to find that most—77.3%—of the Medicaid enrollees reported that the managed care plan they were on was not chosen by them, but automatically assigned to them," said Hanchate, who was the corresponding author of the study.

While the new plans were responsible for screening and providing assistance for social needs, such as food and transportation, 79% reported not receiving any social need assistance.

The findings were recently published in the Journal of General Internal Medicine.

For the study, the research team identified 4,859 Medicaid enrollees and 5,137 individuals with private insurance, along with survey data from 398 Medicaid enrollees in Forsyth County. Researchers collected data on engagement in managed care plan selection, continuity of care, receipt of social need services and primary care use.

Other key findings:

• 19.2% reported lacking assistance with plan choice.
• 13.1% of enrollees reported insufficient information about the transition.
• 5.9% were assigned to a different primary care provider.

Also concerning was that there was a 7.1% reduction in the volume of primary care visits among Medicaid enrollees relative to privately insured enrollees. However, Hanchate acknowledged that the transition occurred during the COVID-19 pandemic when many patients experienced disruptions in health care access.

Researchers also conducted focus groups with 22 Medicaid beneficiaries from January to March 2022 to gain insight into their experiences with the transition. These findings were recently published in North Carolina Medical Journal.

The team identified four major themes:

• Participants expressed confusion about the signup process.
• Participants had a limited understanding of their new plans.
• Participants expressed difficulty accessing services through their plans.
• Participants primarily noted negative changes to their care.

"Many enrollees expressed fear and confusion related to using their new plans because they were unsure that services would be covered and had trouble reaching a Medicaid representative to help them navigate their services," said Rachel Zimmer, DNP, assistant professor of gerontology and geriatric medicine at Wake Forest University School of Medicine and corresponding author of the focus group study. "Many participants also did not know about the new additional services covered by their plans, such as YMCA memberships, or coverage for over-the-counter medicines."

Zimmer said the focus group findings suggest that plan participants felt unsupported during the enrollment process.

"As Medicaid managed care becomes more established, we hope to see an improvement in the awareness of the policy and choices relating to plans," Hanchate said. "There also needs to be more assistance for social needs to gain better enrollee engagement, which will hopefully lead to improved patient experience, greater health care access and improved patient outcomes."

Both Hanchate and Zimmer agree that the Medicaid program can benefit from listening to the recommendations of members to guide strategies for addressing whole-person care.