Rural Medicare Advantage Members Hit Care Access Snags, Switch Plans

Restricted provider networks under Medicare Advantage plans may pose care access barriers to rural beneficiaries, according to a new study published in Health Affairs.

Researchers used Medicare Current Beneficiary Survey data of 17,888 Medicare beneficiaries from 2010 to 2016 to analyze rural and nonrural beneficiary trends in terms of member satisfaction and care access.

The results revealed that coverage may be lacking for rural beneficiaries due to limited benefits and narrow provider networks.

During this time period, just about two percent of enrollees switched to Medicare Advantage (MA) plans from traditional Medicare plans (1.7 percent of rural enrollees and 2.2 percent of nonrural enrollees). However, 10.5 percent of rural beneficiaries and five percent of nonrural beneficiaries switched from Medicare Advantage to traditional Medicare. In other words, it was more common for a MA member to switch to traditional Medicare than the other way around.

Of eleven measures, including self-reported health and care cost, the researchers found that lower satisfaction with access to care among rural MA enrollees had the greatest association with switching to traditional fee-for-service Medicare.

“Our study shows little evidence that rural enrollees were sicker or had higher need than nonrural enrollees or that higher switching rates among rural enrollees were due to differences in health status,” the study authors wrote. “Importantly, our use of self-reported health status is a strength, as it is less likely to be affected by differences in coding patterns.”

Therefore, health status didn’t impact the results. The researchers were able to compare the rates of switching plans among rural and nonrural beneficiaries without the data being skewed due to one group having worse health than the other.

Consistent with previous research, the study found that rates of switching from MA to traditional Medicare were higher among those who used costly services.

Specifically, 15.1 percent of rural MA enrollees and 8.5 percent of nonrural beneficiaries who had acute hospital visits switched from MA to Medicare plans, compared to the overall rate of switching among rural and nonrural beneficiaries of 10.5 percent and five percent, respectively.

This finding suggests that rural enrollees within the MA program who require costlier care may face even more challenging care access barriers, the study authors noted.

“Switching between Medicare Advantage and traditional Medicare is not necessarily undesirable if it results in greater alignment between plan characteristics and enrollees’ needs,” the authors wrote.

“From a policy perspective, however, the large differences in switching between rural and nonrural enrollees that we observed are concerning. Specifically, our findings suggest that urban-rural differences are linked to dissatisfaction with access to providers among rural enrollees, likely driven by more restrictive provider networks in Medicare Advantage.”

Under MA’s capitated payment model, most plans have smaller provider networks compared to traditional Medicare fee-for-service. While studies have shown that urban MA networks have expanded over time, this is not the case in rural areas where physician density is low. The researchers suggested policy interventions to address this.  

“Developing policies to incentivize the health care workforce to practice in rural areas may alleviate these shortages,” they wrote. “For example, loan repayment or forgiveness programs may attract needed health care professionals in a Health Professional Shortage Area.”

In addition, CMS could change MA network adequacy standards for rural areas to ensure that members have access to providers who offer high quality care and a variety of services. 

In order to expand the MA program in rural areas, it may be necessary to put policies in place that will incentivize rural providers to provide high-quality MA coverage.

“Offering a rural payment add-on for plans that operate in rural areas may incentivize the delivery of high-quality care in rural areas,” the authors explained. “Providing such financial incentives may induce existing MA plans that operate in rural areas to broaden networks and improve quality as well as inducing high-quality plans in nonrural areas to expand their service areas.”