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Thursday, March 23, 2017

Driving High Value Behaviors in Medicaid Plans

In the Medicaid space, as in all of the health care system, a high-performing plan that improves health outcomes, optimizes risk adjustment and meets quality standards requires member engagement. More than just a buzzword you keep hearing, member engagement really is effective — consumers want to be engaged in their health care decisions, and those who are tend to be healthier as a result. Without an engaged population, Medicaid health plans will struggle to meet HEDIS quality measures, maximize pay-for-performance results and keep health care.

However, achieving such engagement and driving healthy behaviors is not a accomplished with a onesize-fits-all program. And when it comes to engaging Medicaid members, there are unique challenges. Medicaid members may face significant barriers to receiving the appropriate care—whether barriers of language or transportation, or simply being overwhelmed by the complexities of the health care system. How can we engage such members, close gaps in care and improve quality scores?

Medicaid performance ratings are unique to each state, but are generally based on three components: clinical quality management, member experience and plan efficiency. And now, such performance indicators are arguably more important than ever, as significant changes are on the way for Medicaid. Replicating what they’ve done for Medicare regulations, CMS is moving forward with the implementation of a mandatory quality rating system and a Medical  Loss Ratio of 85% for Medicaid managed care organizations (requiring that at least 85% of plan revenue be allocated to health care services, covered benefits and quality improvement efforts—such as rewards and incentives (R&I) programs).1 With these new regulations, and as more and more states loosen the rules and, in some cases, require wellness incentives, the stage is set for Medicaid plans to maximize their performance—and their economic returns—through the use of member engagement programs.

There are in fact a number of companies that specialize in this space, which will facilitate the change from FFS to a value based system.  In the past Medi-cal plans have been negligent, attempting to minimize what they perceived to be a waste of resources. The playing table has changed, largely thanks to HEDIS Scores and incentives.  It will be particularly effective in Medicaid Managed Care Plans.

Who are these people?

Medicaid provides health coverage to one in five people—that’s almost 70 million people with $440 billion in expenditures, and those numbers are only going to grow higher.2 Because they are comprised of distinct, diverse and hard-to-reach audiences, engaging these members requires a deeper understanding of their needs, behaviors and attitudes.

The largest and most recognizable groups within the Medicaid population are children, non-disabled adults, the dual eligible, individuals with disabilities, and pregnant women and newborns. And while, of course, no two members within these groups are the same, we can identify some general characteristics to give a better sense of who comprises these groups and the barriers they may face. We’ll start with the largest group: There are around 43 million children on Medicaid.3 Many of them are living in foster care, moving around between homes, guardians or parents. And a significant number of these children have special health care needs. Simply put, with such a large degree of movement and a lack of independence, these children can be very hard to reach. Creating a rewards program that anticipates and allows for changing residence and guardianship can be key to reaching children on Medicaid.

Close to 11 million non-disabled adults are Medicaid members.4 They are parents and caretakers, adults without dependent children, and low-income adults. Members of this population may be medically needy, and though it differs state by state, adults who fall 133% below the poverty line qualify for Medicaid in states that have adopted the Affordable Care Act Medicaid expansion.5 This tends to be the most active Medicaid population, in terms of health care usage. But while they may be more engaged in their care, it’s important to help guide their usage toward high-value behaviors. The next largest population is the dual eligible. These limited-income Medicare members comprise about 9.6 million of the total Medicaid population.6 They frequently have disabilities or comorbidities, and 21% are institutionalized.7 These members may not only have greater health care needs, but also may be housebound, increasing the difficulty in reaching them and encouraging them to make and keep doctor appointments. Including behaviors for your Medicaid rewards program that can be done in the home via in-home test kits can be an effective way to reach this population. Individuals with disabilities make up about 8.8 million of the Medicaid population.8 They tend to be the most diverse group, with a wide range of disabilities and, often, several different conditions. As a result, their health care needs may be more complex and a holistic approach is needed when reaching out to these members, whether as a provider or a plan offering a rewards program. Finally, 40% of US births are covered by Medicaid.9 Pregnant women on Medicaid may be adolescent, may not have planned for their pregnancies, and may not prioritize the importance of care. However, Novu data indicates this high-risk population can be effectively engaged with a rewards and incentives program.

Firstly, more than 61% of all adults on Medicaid have at least one chronic or disabling condition.10 These notable levels of chronic and comorbid illness—including physical conditions like diabetes, cardiovascular disease and respiratory disease as well as mental illness—indicate the considerable health care needs of these Medicaid members. Their needs are complex, and they require a holistic approach to their care. For plans and providers, it is essential to consider the whole member, not just the disease. Secondly, in a lot of cases, there is simply a lack of awareness of coverage and eligibility. Although members must first submit a Medicaid application, they are afterwards often auto-assigned to Medicaid health plans, and therefore may not even know they qualify for services or are a part of the plan. Even if they are aware of their Medicaid coverage, a member’s eligibility may vary over time if their income rises or falls, or they move across state or county lines. This can make reaching the right member at the right time—when they qualify for Medicaid and are enrolled in a plan—a more difficult proposition. Thirdly, low health literacy is compounding these difficulties. A large majority of Americans have trouble  using the everyday health information that is routinely available in our health care facilities, retail outlets, media and communities. Only 12% of American adults have proficient health literacy to manage their health11 and individuals with low health literacy have a 50% increased risk of hospitalization.12 On top of which, Medicaid is a notoriously complex program, with so many variances across state and county boundaries, that it can be difficult for members to understand and take advantage of the perks and plan benefits available to them.

In fact, 30% of dis-enrollments are the result of a lack of understanding of Medicaid and plan benefits.13 This goes to show that a Medicaid member who is confused or overwhelmed by the information and processes they encounter in the health care system is far less engaged with their care, if not actively disengaged. Consider also these various barriers a Medicaid member may face—members may not easily be able to make it to doctor appointments due to lack of transportation, childcare conflicts or working multiple jobs, and may have language or cultural barriers. These members may not have a consistent address, phone number, or Internet access, making it, logistically, more difficult to get—and remain— in contact with them. In addition, with economic hardships, taking care of their health simply may be less of a priority for Medicaid members. With these potential hurdles standing between your program and meaningful member engagement, it’s especially important to design an experience that meets members where they are, and makes it easy for them to participate. Of course, there is no one-size-fits-all solution for engaging Medicaid members. With different measures across different states and counties, the definition of success will vary depending on your plan’s location. The following are a series of essential steps to creating a successful Medicaid R&I program—one that will drive incremental performance, improve HEDIS or other quality measures, as well as reduce costs. However, as you continue reading, consider the following strategies and approaches in light of the measures that apply to your particular state or contract.


Member engagement is crucial to improving health outcomes, yet Medicaid members can be especially hard to reach. But as we’ve discovered, Medicaid engagement programs can be a remarkably effective way to break through those barriers to drive high-value behaviors, encourage a healthy lifestyle and improve HEDIS quality measures, ultimately affecting Pay-for-Performance. The proof? At Novu,  programs have driven a 70% increase in gap closure, a 7% increase in activation among the hardest-to-move populations and an impressive 83% participation rate.

To create a successful program with long-term results like these, Medicaid health plans need to cultivate and nurture relationships with members before and after activation. This means developing a simple and easy-to-use program, segmenting and targeting the appropriate members to activate, determining the reward types and values members respond to, and adopting an omni-channel approach aligned with the consumer lifecycle. Together, these strategies work toward driving member engagement because they hinge on treating members as unique individuals— understanding their needs and expectations, reaching out to them when and where they are, and personalizing the experience for their health journey.

Finally, the administrative and enrollment process must be simplified. Health education and literacy depends upon repetitive learning, like all education.   It should be a topic taught in middle and high schools.

Driving High Value Behaviors in Medicaid Plans

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