"Broadening the Provider Community with Commonwealth Care MCOs" by Christina Severin

This article is more than 14 years old.

There is a quiet buzz emerging from some Commonwealth Care members and member advocates about Commonwealth Care members being locked into specific health plans. (As a general rule, upon enrollment and subsequent eligibility redetermination, Commonwealth Care members have 60 days to change health plans, and then remain members of their plan for one year.)

Certainly, the concept of a lock-in is not unique to the Commonwealth Care program; an annual lock-in is the norm for every person involved in employer-sponsored insurance. The imperative of the lock-in is to create a stable population with reasonable plan tenure. This is a fundamental concept of insurance and affords continuity of engagement with a health plan’s services.

Behind the buzz about the lock-in lurks a larger issue.

While price is obviously a factor in plan choice for premium-paying Commonwealth Care members, the debate around the lock-in rests solely with fully subsidized members. That’s because these “eligibles” are the only ones subject to “auto-assignment” to a plan, assuming they do not choose a plan within 14 days of enrollment.

So, what’s the underlying issue? All Commonwealth Care plans are mandated to offer the same benefits package, which is a product akin to Medicaid — very robust, very comprehensive. The issue lies in the pockets of providers choosing not to do business with all participating Commonwealth Care health plans in their areas. Interestingly, in these pockets are health centers and hospitals that have traditionally been considered part of the safety net health system, with strong missions to care for underserved populations.

The Massachusetts commercial market seems not to have experienced similar issues around what might be characterized as market exclusivity or semi-exclusivity. The vast majority of Massachusetts providers and hospitals participate with the majority of commercial carriers, including Tufts Health Plan, Harvard Pilgrim Health Care, Blue Cross Blue Shield. Although commercial business represents a very small percentage of safety net providers’ payer mix, there still has been a willingness to openly participate with all interested commercial health plans. Presumably, this approach assists them in ensuring that their doors are open to all members of their communities. In the experience of Network Health, this unwillingness to contract with MCOs has not been driven by an articulated, legitimate business reason, such as a lack of competitive rates or poor member satisfaction.

Let’s take a real scenario to illustrate the implications to this issue: A provider chooses not to contract with MCO X. Patients present for care to this provider, and they are enrolled with MCO X — the same MCO that the provider declined to contract with. As a result, the provider complains that the member is experiencing access-to-care issues and needs a longer opt-out period! You don’t need to be vascular surgeon to deduce that the real issue may not be the lock-in, but rather an issue of providers engaged in selective contracting. Unfortunately, this tactic unfairly places members at the center of the issue.

So what’s the cure? Extending or eliminating the lock-in period will not solve the problem. No, the answer is providers engaging in contracting opportunities with health plans offering state-subsidized insurance in a manner that is comparable to the way they engage the commercial health plan market.

Ultimately, we hope that MCO enrollment for Commonwealth Care is driven by meaningful factors like monthly costs and health plan quality. Limiting access to markets runs counter to some of the core principles behind health care reform; it is only through fair and open contracting that health care reform can flourish and true member choice can be assured.

Christina Severin is executive director of Network Health, a health plan with more than 116,000 low- and moderate-income members with state-subsidized health insurance across Massachusetts.

This program aired on June 15, 2007. The audio for this program is not available.