What if they gave a managed care plan and nobody came?

That seems to be the problem with California’s ambitious effort to enroll more than 400,000 low-income seniors and younger people with disabilities into a fully-integrated care program that covers both medical treatment and long-term supports and services.  The idea has enormous promise, but relatively few Californians seem willing to participate. And many who have been automatically enrolled are dropping out.

The California program, called Cal MediConnect, is a demonstration program aimed at the so-called dual eligibles–people who receive benefits from both Medicaid and Medicare. The goal is to improve health outcomes and save money by managing care for those who are high-risk and high-cost patients.

Under the California experiment, dual eligibles are automatically signed up for a managed care plan but can choose to opt-out. They are also free to drop coverage at a later date if they are not satisfied with their care.

As of November 1, only about 50,000 people enrolled in the seven counties where the pilot program is running. But 100,000 who were given coverage said, “No thanks.”

In Los Angeles County, where about half of all potential enrollees live, monthly opt-out rates have been as high as 50 percent. Across the state, they have been averaging about one-third.

David Gorn at California Healthline wrote a detailed description of what’s going on in L.A. County here.  Perplexed officials are trying to understand why so many people are unwilling to participate.

One theory is that consumers fear losing their providers or worry that benefits will be limited in managed care. Some observers think this concern is being driven by doctors who believe they can make more money in traditional fee-for-service medicine than in managed care, where they may have to accept lower fees in return for more network referrals.

Melanie Bella, director of the Medicare-Medicaid Coordination Office at the federal  Center for Medicaid and Medicare Services (CMS) seems convinced that’s part of the problem. She has warned providers to stop discouraging patients from choosing managed care.

Some advocates have been skeptical of the plans as well, arguing that the enrollment design is unfair to low-income people.  One problem: Many potential enrollees are confused by complicated paperwork, especially those for whom English is not their first language.

California is the latest example of the struggles of this ambitious program. New York State has twice delayed  and scaled back the rollout of its program, aimed at 118,000 elderly and disabled residents of New York City and surrounding counties. For a more detailed look at the New York and Florida programs, you can look at a paper I wrote for the Catholic Health Association (available for free download here).

And in Massachusetts, which opened its plan about 14 months ago, only about 18,000 out of 95,000 eligible people had enrolled through November. Of those who were auto-enrolled, about 28 percent dropped out—much lower than L.A. county.

When Massachusetts asked people why they were reluctant to enroll, most said they feared having to change doctors or worried that they’d be unable to get the care they need.  Those who have enrolled tend to be very high-cost users, a phenomenon that worries the managed care companies and could lead to higher rates.

The fear of having to change doctors has plagued many efforts to integrate care for the frail and poor elderly or younger people with disabilities. For instance, enrollment in PACE programs has lagged for decades for much the same reason.

There is some irony in all this. Many of those eligible for these programs are currently getting terrible care in the highly fragmented Medicare and Medicaid systems. They face high rates of complications, emergency room visits, and hospital admissions. And while many older adults in traditional Medicaid are likely to end up in nursing homes, well-run integrated care programs are geared to keeping them at home.

Interestingly, while poorer and more frail seniors seem reluctant to participate in managed care models,  healthier, higher income seniors are enrolling in Medicare’s managed care plans, called Medicare Advantage (even though those do not offer supports and services).

The state managed care demonstrations have enormous potential, but so far at least, the experiment is disappointing. States and managed care organizations are going to have to do a much better job selling this coverage if the effort is to succeed.