Whose Role Is It Anyway? Beneficiary Engagement During the Transition to Medicaid Managed Care in North Carolina

Abstract

Empowering beneficiaries to choose a health plan that meets their health needs during the transition to Medicaid managed care is critical to promote informed decision-making. This study uses North Carolina’s transition under the 1115 waiver to examine the role of the state, health plans, and providers in informing beneficiaries about the transition. We reviewed policy documents and interviewed 43 individuals representing provider practices and 10 representing the State Department of Health and Human Services and health plans between December 2020 and September 2021. Interviewees from the state described strategies to encourage beneficiaries to select a health plan. Participating practices shared that their patients were unaware or confused about the transition. These concerns led practices to engage beneficiaries and contract with all health plans to ensure continuity of care, contributing to administrative burdens. While the state made significant efforts to engage beneficiaries, the interaction between beneficiaries and providers was still critical.

Introduction

Reforms or changes to Medicaid programs are often done with the goal of improving health care outcomes in a state; however, policy changes affecting the Medicaid program are inherently disruptive to the status quo (Feder, 2014; Oberlander, 2016), which creates new work routines. In the case of a state transitioning from fee-for-service (FFS) to Medicaid Managed Care, the disruption requires millions of Medicaid beneficiaries to enroll in plans, which can involve complex decisions about plan options that they are not accustomed to (Carman et al., 2013; Kurtovich et al., 2010). Medicaid beneficiaries often face communication challenges due to lower literacy, limited English proficiency, lack of trust in the health care system, or disability (Byrd et al., 2017; Coughlin et al., 2008; Kaplan et al., 2000), which may impact their knowledge, time, and trust in engaging with this process and selecting a health plan. Hence, building beneficiary knowledge about health plans to ensure the selection of a health plan that meets their health care needs and improves access to health care services requires significant beneficiary engagement effort (Barth & Ensslin, 2015; Holahan et al., 1998; Williams, 2017). [Note: Throughout this paper, we use the term “beneficiaries” because it is used by North Carolina Medicaid for those who are commonly called “eligible.”]

Beneficiary engagement during the transition to Medicaid-managed care is essential for increasing enrollment in health plans, identifying unanticipated needs, and achieving better population health outcomes (Crable et al., 2022; Zhu et al., 2021). However, health care reform efforts historically have ignored the importance of engaging patients for plan selection (Bruno, 2018). For instance, 2.3 million Medicaid beneficiaries were eligible for managed care plans in the early 1990s across 13 states that implemented Medicaid managed care programs; yet across states, 9 out of 10 did not choose a plan and, therefore, were auto-enrolled in managed care plans (Holahan et al., 1998). Only a few states reported high health plan selection by Medicaid beneficiaries by the mid and late 1990s (Fraser et al., 1998). These states mostly used government offices and physician practices as enrollment sites (Fraser et al., 1998).

Some empirical studies assessed beneficiaries’ understanding of Medicaid managed care and found that enrollees did not have enough information about the health plans and service coverage (Gibbs et al., 1996). For example, in 1995, 25% of new Medicaid managed care enrollees in New York reported not knowing the difference between FFS and managed care (Morton, 1998). Similarly, a 1995 study revealed that Medicaid beneficiaries described the need for more information, distrusted plan representatives who did not have the experience of using publicly funded services, and perceived difficulty in changing health plans after enrollment (Gibbs et al., 1996). More recently, a 2016 study conducted a content analysis of information available to Medicaid managed care enrollees in Florida to understand whether they were adequately informed. This study found that while the information minimized cognitive complexity, information was lacking in critical areas, such as the significance of beneficiaries’ choices (Peterson & Hyer, 2016). Although recent literature calls for incentives for efforts that engage patients from diverse backgrounds in policy design and implementation (Armstrong et al., 2013; Carman et al., 2013; Maurer et al., 2019; Zhu et al., 2021), little empirical evidence exists about how beneficiaries are engaged to promote informed decision-making and enrollment in managed care plans and by whom.

On July 1, 2021, the North Carolina Department of Health and Human Services (referred to as “the state” hereafter) transitioned the Medicaid FFS model to a managed care model; the stated goals were to build an innovative health system that provides quality care to its beneficiaries and improves population health (Cohen, 2019; “Transformation—NC Medicaid,” n.d.). At the launch, 1.6 million Medicaid beneficiaries in North Carolina started receiving services through one of the five prepaid health plans. In this paper, we examine the approaches used by the state and health plans to communicate information about the transition to Medicaid beneficiaries and the role that physicians played in “filling the gaps” in these approaches. Our findings have implications for future policy changes that rely on physician practices for this type of complementary, nonmedical role.

New Contribution

We examine the role of the state, health plans, and providers in beneficiary engagement leading up to the transition to managed care, how strategies were coordinated among these groups, and their perceptions about the successes and challenges of these strategies. Understanding how North Carolina engaged beneficiaries offers important lessons for other programs and policymakers pursuing Medicaid transformation to achieve the quadruple aim of improving patient experience and population health, reducing costs, and improving provider satisfaction.

Theoretical Framework

According to the Center for Advancing Health (2014), patient engagement is “characterized as actions that individuals must take to obtain the greatest benefit from the health care services available to them or, more generally, the relationship between patients and health care providers as active patient involvement in health care is promoted.” Drawing on this definition, we conceive of beneficiary engagement as the ability of Medicaid beneficiaries to choose a plan that provides the greatest benefit to them and their families under the managed care model. We draw on the beneficiary engagement process described by the National Medicare Education Program launched by the Centers for Medicare and Medicaid Services, according to which beneficiaries go through several steps to find a plan that meets their needs (Williams, 2017). First, beneficiaries must compare different Medicaid health plans, which includes (a) finding out what health plan choices they have; (b) gathering information on different health plans; (c) comparing the advantages and disadvantages of each health plan, such as benefits, in-network practices and hospitals, and the perceived quality of health care provided; and (d) choosing the plan that meets their health and social needs. Building beneficiary awareness and changing beneficiary behavior to ensure enrollment in health plans require significant beneficiary engagement efforts (Barth & Ensslin, 2015, 2017).

Many stakeholders, such as policymakers, health care providers, and managed care organizations, are involved in disseminating information to beneficiaries and facilitating informed decision-making about health plans. However, beneficiary engagement is only successful when the stakeholders understand beneficiary communication needs, have shared goals, and coordinate activities and resources (Bullock et al., 2021; Crable et al., 2022; Salloum et al., 2017). In this analysis, we focus on (a) why and how different stakeholders engaged beneficiaries and (b) how the efforts and resources were coordinated among the stakeholders.

We apply conceptual lenses from policy implementation literature to analyze the roles of stakeholders and the coordination of activities and resources between the stakeholders to meet beneficiary communication needs. According to the Conceptual Framework for Policy Implementation, the relationship between different stakeholders for successful implementation can be determined by (a) the level of shared values and beliefs, (b) goal alignment, (c) visibility of roles, (d) the degree of communication, (e) active engagement and feedback loops, and (f) coordination of actors and activities across levels (Bullock et al., 2021). We draw upon this framework to examine activities performed by the state, health plans, and provider practices for beneficiary engagement, with a focus on the clarity of their roles and the level of bi-directional communication, feedback, coordination, and support for their activities.

Study Data and Methods

In 2015, the North Carolina General Assembly enacted Session Law 2015-245, which directed the State Department of Health and Human Services to transition Medicaid and NC Health Choice programs from the FFS model to managed care. On Feb 4, 2019, the state selected five health plans through a competitive request for the application process, of which four offered coverage statewide and one offered coverage in three out of six NC regions (Managed Care for Providers, 2019). The health plans cover the same core services provided under the FFS model; however, there are incentives built in for health plans to focus on prevention and care management. Health plans have the latitude to offer extra benefits to beneficiaries, such as gym membership, cell phones, and school supplies (View Health Plans—NC Medicaid Managed Care, n.d.) Because health plans have overlapping coverage areas and networks and offer a wide variety of benefits, it is important for beneficiaries to understand the differences and select the one that meets their needs.

During the transition from the FFS model to managed care, the state worked with the health plans, providers, community-based organizations, and beneficiaries to implement this complex change. Notably, the preparation and launch of this transition occurred during the COVID-19 public health emergency (PHE), which led to a delay in the launch of the transition from November 2019 to July 1, 2021. Nearly 1.6 million beneficiaries were eligible to transition to a health plan during the open enrollment period between March 15, 2021, and May 14, 2021 (“NCDHHS Launches Statewide Open Enrollment for NC Medicaid Managed Care—NCDHHS” 2021; “Standard Plan Auto—Enrollment Fact Sheet—NC Medicaid” 2022). Beneficiaries who enrolled in a health plan during open enrollment could select a primary care provider from a list of contracted providers. In the absence of selecting a plan and primary care provider during the open enrollment period, beneficiaries would be auto-enrolled to a health plan and auto-assigned to a primary care provider. The state auto-enrolled beneficiaries based on an algorithm that included the following components: (a) beneficiary’s geographic location; (b) historic provider-beneficiary relationship if available in recent claims data; (c) plan assignments for other family members; and (d) equitable plan distribution with enrollment subject to health plan enrollment ceilings and floors (“Transformation—NC Medicaid,” n.d.; “Standard Plan Auto-Enrollment Fact Sheet—NC Medicaid” 2022).

This study is part of a larger evaluation of the 1115 Medicaid waiver, which includes claims analysis, provider surveys, and interviews with multiple stakeholder groups. The qualitative component of the evaluation began in December 2020. Our semi-structured interviews with the provider practices occurred before the launch date of July 1, 2021, between December 2020 and May 2021, and with the state and health plan staff after the launch date of the transition from Medicaid FFS to managed care between July and October 2021. Drawing on the literature, interviews with provider practices covered a wide range of topics, including awareness of the transition, preparation undertaken by stakeholders to transition to managed care, challenges faced during the preparation, support needed, and the impact of the COVID-19 public health emergency on the transition. Subsequently, the initial impressions of data from provider practices informed the interview guides for the state and plan. The interview guides for provider practices, health plans, and the state are available in the supplemental file. In this study, we focused on data relevant to beneficiary engagement and publicly available policy documents to understand the roles of different stakeholders in beneficiary engagement, how engagement strategies were coordinated, and the challenges of beneficiary engagement. We selected a focus on beneficiary engagement because of its salience to provider practices during our interviews.

We identified potential interviewees from multiple sources, including data from Medicaid provider files shared by the state and publicly available information (e.g., from web searches). We purposefully sampled health care practices based on their proportion of Medicaid beneficiaries, provider specialty (family medicine, pediatrics, OBGYN, behavioral health), and geographic location. We selected practices with a range of Medicaid beneficiary volumes, but we prioritized providers with larger proportions of Medicaid beneficiaries because we believed these providers would be more likely to continue Medicaid participation after the transition to managed care and would be better positioned to speak about the impact of the transition on their practices. We selected provider specialties that deliver primary care or behavioral health as these services were a priority for Medicaid managed care. Finally, we aimed for geographic diversity (the six plan regions dividing the state) to account for variability in coverage by health systems and health plans across regions of the state (NCDHHS, 2020).

Using the criteria discussed above (volume of Medicaid patients, provider specialty, and geographic locations throughout the state), we conducted phone and email outreach to 282 health care organizations (health systems and physician practices, some of which were affiliated with health systems). Of these, 190 did not respond, 36 could not be contacted because of wrong contact information, 10 were excluded because they did not meet the inclusion criteria, and 3 declined to participate. The response rate was expected given the pressures health systems and provider practices faced in response to the COVID-19 public health emergency. We completed interviews with representatives of 43 provider practices and health systems. We also interviewed five staff members representing the state and employees representing each of the five health plans.

All interviews were recorded and transcribed verbatim. Two research team members read transcripts to identify emerging themes. A preliminary codebook was developed deductively based on relevant literature and initial impressions of the data and then revised inductively, drawing on the topics that emerged in the data, such as beneficiary education and outreach. Two team members independently coded five interview transcripts for the adequacy of the codebook and agreement on meanings and the application of codes. The agreement was 75% for the first two transcripts and increased to 95% after coding five transcripts. Most disagreements concerned the interpretation of codes and clarity of code definitions. If the coders could not resolve disagreements, additional team members were included in the discussion to reach a consensus. Following this process, a few minor changes were made to the codebook, specifically, the addition of a new code (i.e., to capture perceptions about the patient’s level of awareness of the transition) and a few sub-codes (e.g., challenges providers faced, such as patient attribution). The two coders coded the remaining transcripts individually, bringing discrepancies for research team discussion to maintain agreement on interpretations. Two members reviewed the coded data about beneficiary engagement and analyzed them for emerging themes. During analysis, our team wrote memos to facilitate a move from description to interpretation of the data.

Results

Our comparative data from provider practices, the state, and health plans illustrate key themes that may shape beneficiary engagement efforts in health care reform. Table 1 shows the characteristics of all interviewees. The state and health plan interviewees included staff involved in various aspects of Medicaid transformation (e.g., marketing, clinical strategy, and population health). The representatives from provider practices were facility administrators, health system leaders, and providers. Most interviewees represented behavioral health, pediatrics, family medicine, internal medicine and obstetrics. The proportion of patients insured by Medicaid at the participating practices varied. Eight practices had less than 25%, six had between 25% and 50%, 20 had more than 50%, and seven were unsure about the proportion of Medicaid beneficiaries on their patient panel. The participating practices represented all the regions identified by the state Medicaid program (NCDHHS, 2020). At the time of the interview, 27 participating practices had contracted with at least one health plan. Interviewees interviewed earlier in the study period were still gathering information about the contracts or were unsure about their decision to contract.

Table 1.

Characteristics of the Study Interviewees in the Analytic Sample, 2020–2021.

Interviewee organizations	N	Percent
The state	5
Health plans	5
Healthcare practice characteristics	N (total 41)
Region
1	5	12.2%
2	3	7.3%
3	9	21.9%
4	14	34.1%
5	8	19.5%
6	2	4.8%
Type of Practice/specialty
Behavioral Health	15	36.6%
Family Medicine/Internal Med	11	26.8%
Pediatrics	11	26.8%
Obstetrics and Gynecology	4	9.75%
Affiliation
Health Systems	4	9.75%
System-affiliated practices	4	9.75%
Independent practices	28	68.3%
Federally Qualified Health Centers	5	12.2%
Medicaid Beneficiaries
Less than 25%	8	19.5%
25% to 50%	6	14.6%
More than 50%	20	48.8%
Unsure	7	17.1%
Interviewee Characteristics a	N (total 43) b
Leadership	15	34.9%
Providers	8	18.6%
Facility administrators/staff	20	46.5%
Total participants (state, plans, and provider practices)	53

^aLeaders included roles like vice presidents and chief executive officers. Providers included physicians, nurses, physician assistants, and therapists. Facility administrators/staff included roles like billing managers and office/practice managers. ^bWe interviewed more than one participant at two provider practices.

We examined three themes particularly salient to the role of stakeholders and coordination of beneficiary engagement activities to maximize outcomes: (a) The state and health plans employed a wide range of beneficiary engagement strategies, but the appropriateness and impact of the strategies were unclear, (b) Providers stepped in to help inform beneficiaries about the changes to Medicaid and assist with the challenges they faced, and (c) Provider burden and support needed for their beneficiary engagement efforts is substantial.

The State and Health Plans Employed a Wide Range of Beneficiary Engagement Strategies, but the Appropriateness and Impact of the Strategies Was Unclear

Based on the review of publicly available policy documents, the state and health plans were the main stakeholders with well-described beneficiary engagement roles, whereas providers were not described as having a role in beneficiary engagement efforts (“Beneficiaries in Medicaid Managed Care,” 2018; “North Carolina’s Proposed Design for Medicaid Managed Care,” 2017).

The interviews with the state and policy documents showed that the state invested in a wide range of beneficiary engagement efforts to inform beneficiaries of the change and alleviate their concerns or fears about its impact. At the population level, the state used mass media campaigns via TV, radio, social media, and mail. Transition notices, health plan choice guides, reminder cards, and enrollment packages were mailed to beneficiaries to provide information about the change and encourage beneficiaries to choose a plan (Cohen, 2021; Karolak, 2019). Due to the public health emergency of the COVID-19 pandemic at the time, in-person outreach events were limited; therefore, virtual educational meetings were hosted to inform beneficiaries. The state provided further support to beneficiaries via enrollment brokers, ombudsmen, and health plan member services to raise awareness, encourage plan selection rather than auto-enrollment, provide counseling on the selection decision, and address beneficiary questions and concerns. These strategies were refined based on ongoing stakeholder feedback, which included a member (beneficiary) advisory committee and providers (“Medical Care Advisory Committee,” n.d.). Prior to the PHE, the state had planned to offer one-on-one engagement by enrollment brokers at local Departments of Social Services (DSS); however, this approach ultimately was not used.

As per policy documents and interviewees from health plans, the state permitted health plans to engage in marketing activities (“Beneficiaries in Medicaid Managed Care,” 2018). The state oversaw these activities to protect beneficiaries from coercion. In addition, health plans were required to support the transition of beneficiaries to managed care after they selected a health plan or were auto-enrolled to a health plan. The key engagement strategies included adequately staffed and trained member services departments with a toll-free telephone line, websites, and mailing welcome packages. Moreover, health plans were required to coordinate their outreach and engagement efforts with the enrollment brokers and ombudsmen to avoid any confusion among beneficiaries (“Beneficiaries in Medicaid Managed Care,” 2018; Pearson et al., 2018). These observations illustrate that the state had a primary role in beneficiary engagement efforts, particularly in overseeing beneficiary engagement efforts, raising beneficiary awareness about managed care, and providing resources to support enrollment in health plans and health plans had a primary role in beneficiary engagement efforts after member enrollment. Table 2 summarizes the range of strategies used by the state, health plans, and providers.

Table 2.

Stakeholder Efforts and Challenges Faced During Beneficiary Engagement Efforts During North Carolina Medicaid’s 1115 Waiver Demonstration.

Stakeholder	Strategies	Challenges
The state	● Mass media campaigns ● Mail ● Enrollment brokers ● Ombudsman ● Providers  • Advisory Committee	● Fewer in-person (e.g., town halls) opportunities due to the pandemic ● No mechanism to know if beneficiaries were aware of resources, like the ombudsman.  • Frequently changing mailing information of the beneficiaries.
Health plans (Managed Care Plans)	● Information on websites ● Member services ● Promotion of benefits/incentives  • Welcome packages	● The perception that beneficiary engagement efforts do not work (expected 40% to enroll)
Provider Practices	● One-on-one information during a clinical encounter ● Mail ● Text, telephone, hotlines ● Connected patients with enrollment brokers.  • Flyers and handouts developed by the state	● Additional time and effort to  ○ answer beneficiary questions during clinical encounters.  ○ Raise self and staff awareness about the health plan coverage and incentives to give accurate information to the beneficiaries.  ○ Reconcile beneficiary physical addresses for the state. ● Additional time and effort to minimize disruption of care for beneficiaries and the financial consequences of wrong auto-assignment.  ○ Contract with all health plans to minimize disruption of services.  ○ Gather information about in-network specialty clinics.  • Inadequate targeted support and resources from the state for patient engagement efforts

The state interviewees reported that the complexity of the transition to managed care and beneficiary characteristics (e.g., education level, lack of consistent phone numbers, and incorrect mailing addresses) hampered the ability to evaluate the usefulness of communication efforts and tailor the messaging to the needs of all beneficiaries. The state interviewees described collecting data on the number of visits to the website, returned letters due to incorrect addresses, feedback on materials from the member (beneficiary) advisory committee, and patient surveys. However, they also reported difficulty in assessing the effectiveness of the communication efforts in a way that would lead to timely, actionable feedback. According to one state interviewee:

There was not a good method in place to find out whether the information that went out to the beneficiaries via website or mail resonated with them and whether they actually felt informed.

This observation illustrates the important difference between obtaining counts of website views and letters distributed versus the perceived usefulness of the information contained within these sources among a heterogeneous population.

The state interviewees expected active beneficiary enrollment to be as high as 40% if the beneficiary engagement activities worked well or as low as 8-10% if they did not. (State, 04). Ultimately, during the open enrollment, only “about 15 percent of the eligible beneficiaries chose a health plan.” Those beneficiaries who did not select a plan were auto-enrolled in health plans and assigned providers based on an algorithm to “preserve the existing patient-provider relationship.” The state also allowed beneficiaries to change their health plan within 90 days of enrollment and ensured flexibility in reimbursement for providers during the initial launch period, covering services provided by both in-network and out-of-network providers at the same rates. The state and health plan interviewees believed that the auto-enrollment worked, generally, with a few concerns from providers about not having beneficiaries on “the roster that would be on there but now assigned to someone else.”

In summary, the roles of the state and health plans in beneficiary engagement efforts were well-described, resulting in significant efforts. However, the mechanisms to assess whether beneficiaries received and understood the information about the transformation were insufficient.

Providers Stepped in to Help Inform Beneficiaries About the Changes to Medicaid and Assist With the Challenges They Faced

The policy documents did not describe providers as having a role in beneficiary engagement efforts (“Beneficiaries in Medicaid Managed Care,” 2018). Similarly, the interviewees from the state did not describe providers as one of the primary stakeholders involved in beneficiary engagement efforts. However, they acknowledged that the state did not routinely engage all 2.6 million Medicaid beneficiaries directly and viewed providers as a source who could “amplify the state’s voice among beneficiaries.” In contrast, interviewees from provider practices perceived themselves to be the undesignated primary group involved with educating beneficiaries. They reported a sense of obligation to perform this role because they perceived many Medicaid beneficiaries to be unaware or unprepared for the transition despite substantial beneficiary engagement efforts by the state and health plans.

Some interviewees from provider practices had concerns about Medicaid beneficiaries being able to access information about the transformation. The website required beneficiaries to download an application, compare the plans, find their provider, and determine whether their provider is in-network with their chosen plan. One health system leader stated,

I’m fascinated by the amount of time and energy on the technical side that the state has put in. . . . .I understand that’s important. I do think as important are the messages to the members [beneficiaries]. And I know there’s a website. I went out to it and looked at how you compare the plans. A lot of the Medicaid population doesn’t necessarily have access to technology to get them to the website.

Similarly, a health system leader described being unaware of “a thoughtful communication plan by the state about how they would engage with subsets of populations who need tailored messaging.” These concerns align with the issue reported by a state interviewee (mentioned above) that there needed to be more efficient methods for gathering feedback about how informed beneficiaries felt even after accessing the available information resources. Many interviewees from provider practices perceived the communication between the state and beneficiaries to be overwhelming for beneficiaries, particularly those with low literacy, mental health concerns, and limited English proficiency.

Interviewees from provider practices shared that the complexity of the transition to Medicaid managed care required tremendous patient education efforts to raise awareness and educate beneficiaries on the process of choosing a plan, for example, what “network means when they’ve been in a program that hasn’t had a network before.” Although the state invested in resources to assist with education, the resources may not have reached all who needed them, possibly because some resources required substantial effort to access or access to the resource was inconsistent. According to one pediatrician in a small independent practice,

When you have a parent call you and says, ‘I’ve called the enrollment broker four times, and I still can’t get my child enrolled,’ that’s a problem.

The interviewees from provider practices perceived this challenge of investing time and effort to connect with the enrollment broker or navigate the website to compare the plans that led Medicaid beneficiaries to seek more information from providers.

Interviewees from provider practices also expressed concern about the completeness of information that beneficiaries could access, specifically the provider list on some health plan websites. Low-quality information had negative consequences for engaged beneficiaries who were at the stage of selecting a plan. According to an interviewee from a large independent practice, beneficiaries could not “find their primary care provider that they have seen for 20 years” as the provider or its organization name was not listed on the health plan website. This concern was attributed to delays in providers contracting with health plans and insufficient enrollment-broker communication with the beneficiaries. For example, one staff member from a pediatric practice stated,

When people ask them [parents/caregivers] who their child’s doctor is, they tell them [practice name] pediatrics. Well, that’s not the doctor’s name. They’ve had enrollment brokers tell them we can’t find them.

Ultimately, interviewees from provider practices described extensive efforts to communicate with the beneficiaries, alleviate concerns, and help them enroll in a plan to ensure a smoother transition for their patients. Practices employed various strategies, such as distributing informational materials, assigning point persons, setting up call centers to answer questions, and communicating with beneficiaries via phone calls, text messages, and letters. One participant discussed how each time the state or health plans distributed information en masse to beneficiaries, they knew about it when “the number of calls asking questions” increased. Whereas some practices endeavored to answer beneficiary questions directly, one family medicine provider/practice manager described their work as an intermediary between the beneficiary and the enrollment broker:

We have patients who reach out to us and ask us to help them fill out their paperwork or help us—help them call and set it up. We get them on the phone, tell the representative who we are, and try to help the patient connect with them. And then, we let the patient talk to that representative on the phone.

In summary, although the level of involvement and the strategies employed varied, providers and staff were active in educating beneficiaries about the Medicaid program’s transition to managed care, particularly how to select a plan and ensure they were assigned to the desired primary care provider.

Provider Burden and Support Needed for Their Beneficiary Engagement Efforts Is Substantial

The state interviewees acknowledged that provider practices had an unassigned role of educating their patients about the transition. To alleviate the provider burden of educating beneficiaries, the state distributed beneficiary-facing information to providers, engaged medical societies, and provided resources such as fact sheets, playbooks, and webinars:

This was sort of a two-fold thing. We wanted to share with providers what we were doing in terms of pushing out information to beneficiaries, what the enrollment broker was doing, and share those same materials with them, knowing that they are a trusted source of information for beneficiaries. But that creates another thing to do, right? If you’re a provider, there’s also, in addition to preparing administratively for this change, you kind of have another role of educating beneficiaries on this change. I think what we tried to do is arm providers with the information that we were pushing out to beneficiaries.

The quote illustrates that even though provider practices were not expected to play a primary role in beneficiary engagement, their relationship with the beneficiaries was leveraged to disseminate information and raise awareness.

To further support providers, the state ensured mechanisms, such as a three-pronged progression, to address any issues that may arise before and during the transition. Providers could contact the ombudsman for resolution if health plans could not address an issue. Unresolved issues would then be escalated to the state (NC Medicaid, 2021). However, this strategy was not specific to beneficiary engagement efforts, and none of the interviewees from provider practices described using it for beneficiary engagement efforts. In the end, interviewees from the state acknowledged that the provider burden was substantial, even with all the resources provided. Similarly, some interviewees from provider practices conveyed that the communication and resources were inadequate, which had consequences for providers’ ability to educate their patients effectively. For example, a participant from a pediatric practice voiced concern about the letters from the Medicaid program confusing patients and reflected on not receiving the beneficiary-facing information (i.e., copies of the letters) in a timely way, which hindered their ability to respond to beneficiary questions:

We had a parent call today to say that she’s received a letter and that she has to choose which health insurance plan to use. We didn’t even know the letter was going out yet.

This perception was shared by several other interviewees from provider practices, highlighting insufficient feedback loops, communication, and coordination of activities between the provider practices and the state. Other interviewees from independent practices described feeling lost because “the information is not consistent, is confusing and keeps changing.” They needed to educate themselves and their staff to help the patients. Patients relied on providers for more information about managed care, which took time away from clinical work for providers. A practice administrator at an independent family practice stated,

We have fliers in the room saying to ask us upfront, but we had to take them down because they wouldn’t ask us. They would ask the providers. What does this mean about this new Medicaid reform, and what will happen? And the providers [at the practice] started saying, “Look, I’m taking too much of our medical time trying to discuss an insurance issue that the state should’ve done this part. It should truly, not be our responsibility.

Ensuring that beneficiaries were assigned to the correct provider was another concern. Provider practice representatives indicated that under the original fee-for-service model, providers completed a form when their patient was assigned to another provider. Under the managed care model, beneficiaries are required to contact the health plan and complete paperwork to change their provider. The interviewees from provider practices perceived this onus on beneficiaries would cause a delay in patient care. In addition, it would have financial implications for providers, specifically as they transition to pay-for-performance and value-based payment models. Interviewees from provider practices expressed concerns about being held responsible for patients who should not be on their panel, losing established patients, which could have implications for their value-based payments, and administrative costs related to changing a beneficiary’s designated PCP if there was a problem during the auto-assignment process.

Interviewees from small and mid-sized provider practices reported that they were not well-resourced to serve in this role. According to one practice administrator at an independent pediatric practice:

It’s a big undertaking, and we’re a mid-sized practice. I don’t have a lot of excess staff sitting around, not doing anything that has time to call patients as well. And then you’ve got to hope you can get them. I’m really concerned about auto-assignment. They (patients) just tell us they didn’t get enrollment packets.

This participant was concerned that beneficiaries would not have the information needed to choose a health plan, leading to auto-enrollment and potentially unwanted PCP assignments if provider practices were not in the provider directory or did not happen to be on recent claims. According to another provider,

A lot of our parents aren’t even familiar with the fact that they’re going to have to select a health plan and a practice and have all that stuff done, or else they’re going to be auto-enrolled. So we have a lot of concerns, especially with our patients. Are there going to be a lot of logistical issues for patients who have come here for years suddenly being assigned to another practice unawares to their parents? So that’s a huge concern of ours.

Most participating practices contracted with all the plans to keep their doors open for all their patients to reduce care disruption. In addition, a few interviewees from small independent practices described proactively identifying in-network specialty providers to minimize delays in care and financial consequences for their beneficiaries and the program. Although health systems and larger independent practices may hire additional staff for outreach, the responsibility of beneficiary engagement fell primarily to the providers for smaller practices. These practices perceived a heavier administrative burden because of the competing priorities and operational challenges of “opening back in-person visits and handling Covid vaccinations.”

Despite the state’s efforts to gather provider feedback through surveys, webinars and by working with professional societies during the months leading up to the transition, some providers still felt they did not have sufficient input or preparation. One state participant suggested that provider feedback specifically about beneficiary engagement efforts prior to the launch may not have been sufficient:

I have not had enough conversations with providers about friction there, right? Like, how well did that work? Did they feel comfortable educating folks on this? Did we do enough or not enough to arm them with the needed information? I think it’s a great question, and I would love a focus group of providers to understand that better.

The state representatives conveyed a strong desire and intention to provide information and other resources for providers. However, robust feedback mechanisms about the usefulness and adequacy of the information and resources were not in place prior to the launch.

Overall, we find that the state, health plans, and provider practices put substantial effort toward beneficiary engagement. However, the role of providers in beneficiary engagement was not clearly defined, causing confusion and frustration among participating provider practices and health systems. Moreover, efforts for bi-directional communication, feedback, coordination, and support for activities to achieve beneficiary engagement goals between all stakeholders were insufficient, leaving provider practices feeling overburdened and unable to address beneficiary needs sufficiently.

Discussion

Our findings highlight factors affecting beneficiary engagement during the North Carolina Medicaid program’s transition from a traditional fee-for-service to a managed care model. Several policy-level factors highlighted in our study have been shown to be critical for successful policy implementation (Aaronson et al., 2021; Bullock et al., 2021), particularly the relationship between stakeholders from the top-down and bottom-up (beneficiaries, providers, health systems, health plans, and policymakers) (Aaronson et al., 2021). According to the Conceptual Framework for Policy Implementation, the relationship between different stakeholders for successful implementation can be determined by (a) the level of shared values and beliefs, (b) goal alignment, (c) visibility of roles, (d) the degree of communication, (e) active engagement and feedback loops, and (f) coordination of actors and activities across levels (Bullock et al., 2021). Our findings highlight that the state and participating provider practices worked toward the shared mission of serving Medicaid beneficiaries. The state’s goals for beneficiary engagement were to provide information, solicit and integrate feedback, maintain existing patient-provider relationships (“Standard Plan Auto-Enrollment Fact Sheet—NC Medicaid” 2022), and ensure access to services (Pearson et al., 2018). However, representatives from provider practices conveyed skepticism and took on beneficiary engagement efforts to ensure care continuity for Medicaid beneficiaries, prevent the foreseeable administrative burden of correcting beneficiary assignment for their staff and the beneficiaries, and prevent the financial consequences of incorrect auto-assignment. Findings from our interviews suggest that the state viewed providers as having an active and important role, but many provider practices were unsure about their role, were overwhelmed with their role in beneficiary engagement and dissatisfied with the support available to them. Moreover, the engagement of provider organizations for feedback on outreach materials was perceived to be inadequate. With the lack of clarity of beneficiary engagement goals and inadequate resources, provider practices took additional responsibilities to prevent unintended consequences of insufficient beneficiary engagement for themselves and beneficiaries, resulting in additional administrative burden. Leveraging providers as one of the key stakeholders in beneficiary engagement efforts before the transition to managed care, clearly outlining their roles and responsibilities, the support and incentives available to them, and incorporating feedback loops to monitor the progress of these engagement efforts might have reduced administrative burdens and led to more streamlined beneficiary efforts.

In the first year of the transition, only 15% of the Medicaid beneficiaries selected a plan despite tremendous efforts by all the stakeholders, which is lower than reported by most other states (Ferber, 1996; Ndumele & Wallace, 2020; “States’ Efforts to Educate and Enroll Beneficiaries in Managed Care,” 1996). Tracking the reach, and effectiveness of each beneficiary engagement effort through focus groups, interviews, and surveys with beneficiaries, providers, and enrollment brokers might have helped identify which efforts were working and make changes to the ones that were not working. While the reasons for the low rates of plan selection are unclear, our data highlights some potential reasons. The interviewees from provider practices described confusion and lack of awareness among their Medicaid beneficiaries and identified possible reasons for the confusion. Interviewees from provider practices suggested beneficiaries may have received materials informing them about the change multiple times and ignored them due to confusion caused by the initial delayed implementation. Another possibility identified by interviewees is that some beneficiaries were unable to comprehend the information in the materials, particularly those with limited English proficiency or other language barriers or mental health conditions. These findings are consistent with the empirical research that suggests that beneficiary communication is more effective when tailored to people’s personal and social contexts (Kaplan et al., 2000; Kurtovich et al., 2010; Neuhauser & Kreps, 2003; Root & Stableford, 1999). In recent years, several evidence-based strategies have been used to improve communication with beneficiaries by tailoring mass media communication to meet the needs of subgroups. They include matching readability to beneficiary literacy levels, culturally relevant concepts, and languages, adapting rather than translating documents to other languages, and using participatory processes to ensure active engagement and feedback loops when developing communication materials (Calderón & Beltran, 2005; Kurtovich et al., 2010; Neuhauser & Kreps, 2003; Root & Stableford, 1999; Zhu et al., 2021). Effective engagement of beneficiaries to design and disseminate educational materials during health reform could yield a better return on investment and achieve the desired outcomes of beneficiary engagement (Hamilton et al., 2021). More specifically, systematic assessment of information directed at beneficiaries about the transition to managed care, including initial input and regular feedback from beneficiary advisory committees, might have resulted in a more user-friendly design and distribution of information.

Also, some beneficiaries may have lacked access to the technology needed for plan selection. The interviewees from provider practices also discussed incomplete provider lists on the health plan website, which could have hindered the ability of Medicaid beneficiaries from enrolling in a plan even though they were ready to do so. Our findings show that provider practices observed that Medicaid beneficiaries who were aware of the change sought more information from the providers. Further research needs to be conducted with Medicaid beneficiaries to understand the barriers that impacted their engagement during the transition to managed care to validate these findings.

Prior work has advocated for the use of implementation science methods to support the statewide change in Medicaid policies (Emmons et al., 2021) because evidence has shown that while expanded Medicaid coverage improves health access, population outcomes such as cancer screening rates still may not be achieved (Huf et al., 2018). Often, the opportunity to utilize implementation science methods is missed (Aaronson et al., 2021; Bullock et al., 2021; Emmons et al., 2021). For example, the evaluation of the 2018 trial of Healthy Behavior Incentive Programs in Medicaid showed that it did not achieve the desired population health outcomes due to poor awareness of the program, poor communication of complex policy changes, and program delivery adaptations that reduced effectiveness (Huf et al., 2018). This example and our findings highlight the importance of careful planning and coordination of beneficiary efforts to achieve the desired effect of a policy change. During the planning and preparation phase, careful consideration could be given to defining the roles and responsibilities of stakeholders, allocating resources, establishing feedback loops, and coordinating activities for beneficiary engagement. Designing communication strategies and outreach materials during this phase could consider identifying and addressing the beneficiary-level barriers preventing their understanding of policy change and its impact on them. Furthermore, outreach materials could be tailored to specific population groups and provider practices. For example, mental health providers may need more simplified language for their patients, whereas practices that serve non-English speakers may need materials in languages other than English and Spanish. Future research is required for testing communication strategies tailored to the social and contextual needs of Medicaid beneficiaries and provider practices during health reform.

Our study highlights the additional administrative work of beneficiary engagement on provider practices, who had a key role in disseminating information. The state provided financial incentives from April 1, 2021, to June 30, 2021, to provider practices with comprehensive care coordination services or those serving beneficiaries from areas of the state with high poverty rates with flexibility in how these additional funds could be used (“Advanced Medical Home Tier 3 ‘Glidepath’ Payments Update—NC Medicaid,” 2021; “Health Equity Payment Initiative Survey—NC Medicaid,” 2021). However, providers in our sample did not identify these incentives as being used to offset the administrative costs of beneficiary engagement. In future efforts, careful planning and appropriate resource allocation to provider practices in the form of targeted short-term financial support or staffing could reduce the administrative burden. Furthermore, close collaboration and coordination of beneficiary engagement activities and tracking ongoing engagement strategies and policy effects over time from policy enactment to implementation could result in the realization of quadruple aim, i.e., better patient outcomes and experience, reduced costs, and better provider satisfaction (Arnetz et al., 2020; Bodenheimer & Sinsky, 2014).

Limitations

Although our findings provide an overview of the beneficiary engagement approach and its consequences in North Carolina, these interviews do not represent all the views of these efforts. Specifically, we did not interview individual Medicaid beneficiaries or member (beneficiary) advisory committee members on their satisfaction and quality of engagement efforts; therefore, we cannot assess beneficiary perspectives of engagement efforts by the state, health plans, and provider practices. We also did not interview enrollment brokers or ombudsmen staff to understand their perspectives on beneficiary engagement. These stakeholders may differ in their engagement goals and experience. In addition, by design, most provider practices in our sample have over 50% of the patient panel composed of Medicaid beneficiaries. Our analyses did not detect differences in the types of challenges experienced by the proportion of Medicaid beneficiaries; however, it is possible that the extent or impact of the burden could be different along this dimension or across other dimensions that we did not sample, such as number of providers in the practice. Future research can highlight the beneficiary engagement goals and experiences of other stakeholders. Finally, the response rate during outreach to providers during recruitment was low, presumably because of the stress of the public health emergency on health systems and provider practices (Balio et al., 2022; Seguin-Fowler et al., 2023; Suslow et al., 2023). However, the nonresponse rate for our outreach efforts did not prevent us from adhering to our purposive sampling approach based on the volume of Medicaid patients, provider specialty, and location within the state.

Conclusion

Although the state made significant efforts to engage beneficiaries in plan selection leading to managed care transition, direct interaction between beneficiaries and their provider is still critical. Provider practices demonstrated commitment to their patients by assisting them during the transition but consistently reported concerns about the enhanced administrative burdens accompanying beneficiary engagement and contracting with five different plans to maintain patient access to care, amounting to an invisible tax on providers. Using strategies like participatory processes for developing outreach materials, defining and communicating beneficiary engagement goals for each stakeholder, ensuring the availability of resources for providers specifically for beneficiary engagement, and building trust among key stakeholder groups prior to implementation could yield better beneficiary engagement outcomes and achievement of the quadruple aim.