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.
Conclusion
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
