Impact of Continued Biased Disenrollment from the Medicare Advantage Program to Fee-for-Service

By Gerald F. Riley
Centers for Medicare & Medicaid Services, Medicare & Medicaid Research Review , 2012: Volume 2, Number 4

Background: Medicare managed care enrollees who disenroll to fee-for-service (FFS) historically have worse health and higher costs than continuing enrollees and beneficiaries remaining in FFS.

Objective: To examine disenrollment patterns by analyzing Medicare payments following disenrollment from Medicare Advantage (MA) to FFS in 2007. Recent growth in the MA program, introduction of limits on timing of enrollment/disenrollment, and initiation of prescription drug benefits may have substantially changed the dynamics of disenrollment.

Conclusions: Despite substantial changes in policies and market characteristics of the Medicare managed care program, disenrollment to FFS continues to occur disproportionately among high-cost beneficiaries, raising concerns about care experiences among sicker enrollees and increased costs to Medicare.


Despite substantial changes in policies and market characteristics of the Medicare managed care program, disenrollment to FFS continues to occur disproportionately among high-cost beneficiaries. Disenrollees had higher risk scores and incurred higher risk-adjusted payments than beneficiaries in FFS. Their high risk scores are in contrast to the risk scores of the general MA population, most of which is enrolled in plans with average risk scores similar to or less than local FFS experience (United States Government Accountability Office, 2010). Recent studies have also shown that MA plans continue to experience favorable selection through enrollment of low-cost beneficiaries (MedPAC, 2012; Riley, 2012). These research findings suggest a pattern of selective disenrollment whereby disenrollees are sicker and more expensive than the beneficiaries who remain enrolled in MA plans. This selective disenrollment potentially increases Medicare costs through the return of high-cost beneficiaries to the FFS sector, leaving behind a healthier and lower-cost population in the capitated MA sector.

The Affordable Care Act mandated changes to MA payment methods that will result in significant decreases in payment rates and bring them closer in line with plan costs. This may intensify pressure on plans to encourage selective disenrollment.

Disenrollees from PPOs and PFFS plans incurred lower payments post-disenrollment than disenrollees from HMOs and similar types of plans, and their average payments were closer to predicted levels. Possible explanations include a less chronically ill disenrollee population from PPO and PFFS plans, or less unmet demand for services when they transitioned to FFS. Less selective disenrollment from PPO and PFFS plans may be attributable to the more extensive network of providers available under these types of plans. Beneficiaries with chronic illnesses have a greater choice of physicians to manage their conditions and have more opportunities to switch providers if they become dissatisfied with their care. This expanded choice of providers may reduce the incentives for chronically ill enrollees to leave these types of plans.…

Earlier studies of the Medicare + Choice plans and more recent studies of the successor Medicare Advantage plans have shown that, when it comes to managed care, the healthy go in and the sick come out. Taxpayers are paying more for the healthier, less-costly patients who are enrolled in the Medicare Advantage plans, and then pay more for the sicker patients who return to the traditional Medicare program (adverse selection). This CMS study adds to that evidence.

One interesting finding in this study is that those enrolled in PPO or FFS Medicare Advantage plans did not show as great post-enrollment cost increases. It is likely that the patients did not experience as much of a limitation in services in PPO plans, such as those offered by Blue Cross and Blue Shield, since their networks tend to include a much larger percentage of the physician population.

There are two important take-home points here. One is that we should stop wasting taxpayer funds on both the excesses of the Medicare Advantage plans, and the costly adverse selection burden that they place on the traditional Medicare program.

The other point is that we should reject the policies of the private insurance sector that is taking away our health care choices by establishing networks of health care providers. Our traditional Medicare program includes a choice of any provider, except for the rare physician who totally opts out of the Medicare program.

For greater economy and expanded choice, we should change to a program of an improved Medicare for everyone.