Health Plans Have an Engagement Problem, but Care Providers Can Help

By Anish Sebastian

A health plan’s success rests on many factors: improving health outcomes, controlling costs, optimizing risk adjustment, and encouraging member adherence to a specific care plan. Member engagement is foundational to all of these goals.

Health plans have struggled to close the loop on engagement for various reasons. This is especially true among Medicaid enrollees, who report more problems with prior authorization and provider availability compared to people with other insurance types and are less likely than their peers to describe their own health as “excellent.”

The Department of Health and Human Services regulates what types of communications health plans can send to their members. Other regulations limit the frequency of communications with members. By limiting communication, the relationship between members and providers can be hindered, and in turn decrease the likelihood that a member will engage with a communication when they do receive one.

This is where care collaboration can make a big difference. A member is much more likely to engage with a communication from a trusted doctor or care team, someone with whom they have a relationship. That communication can make all the difference in how, where, and whether a member receives care. By leveraging the doctor-patient relationship, health plans have the opportunity to reach the members in a way that positively impacts their health and potentially their costs.

Imagine a Medicaid member—let’s call her Sarah—who needs to undergo a series of diagnostic tests to assess her health condition. Sarah receives a notification from her health plan recommending several care facilities where she can get these tests done, along with information about cost-sharing and coverage details.

Scenario 1: Limited Engagement

In this scenario, Sarah receives the notification from her health plan but doesn’t engage with it. She might overlook the message or disregard it because it doesn’t come from her trusted healthcare provider. Without actively considering the recommendations from her health plan, Sarah might decide to visit a healthcare facility based on convenience or familiarity, without fully understanding the cost implications or quality of care provided.

Scenario 2: Active Engagement

Compare this to a situation in which Sarah is engaged with her healthcare journey and values the guidance provided by her healthcare provider. Her provider, Dr. Smith, takes the time to discuss the recommended diagnostic tests with Sarah during her regular check-up, explaining the importance of each test and the benefits of choosing a facility recommended by the health plan. Dr. Smith’s recommendation carries significant weight for Sarah, as she trusts his expertise and values his opinion. With Dr. Smith’s endorsement and the additional information provided by her health plan, Sarah decides to follow the recommended course of action and chooses one of the recommended facilities for her diagnostic tests.

In the above scenario, the health plan is at least aware of Sarah’s needs because it is logged in her EHR. In many cases, a health plan will not find out about a member’s condition until after a claim has been filed, missing a valuable opportunity to surface resources or benefits that could have affected the outcome or perhaps prevented it altogether. Preventive measures are especially impactful for maternity care outcomes, as access to and engagement with prenatal care is one of the primary indicators of maternal and infant health.

Imagine another example: A pregnant Medicaid member, Terri, has recently discovered that she is expecting her first child. Terri schedules an appointment with her obstetrician, Dr. Rodriguez, to begin prenatal care and ensure the health and well-being of herself and her baby.

Scenario 1: Lack of Collaboration and Data Sharing

In this scenario, Terri attends her prenatal appointment with Dr. Rodriguez, during which they discuss her medical history, conduct initial assessments, and develop a care plan tailored to her needs. However, Dr. Rodriguez’s practice operates independently, without integration with Maria’s health plan. Several weeks later, Maria experiences complications during her pregnancy and requires specialized prenatal care services beyond what her current provider can offer.

Due to the lack of collaboration and data sharing between Dr. Rodriguez’s practice and Maria’s health plan, the health plan remains unaware of Maria’s pregnancy until she seeks medical attention for the complications and submits a claim for the services rendered. By the time the health plan becomes aware of Maria’s condition through the claims process, valuable time has been lost, and Maria might have missed out on accessing resources or benefits that could have supported her pregnancy and potentially prevented the complications.

Scenario 2: Collaboration and Timely Data Sharing

Now, let’s consider a scenario where Dr. Rodriguez’s practice collaborates closely with Maria’s health plan, facilitating timely data sharing and communication. During Maria’s prenatal appointment with Dr. Rodriguez, her pregnancy status and relevant health information are promptly shared with her health plan through an integrated tool. This allows the health plan to identify Maria as a pregnant member and proactively reach out to her with valuable resources, support programs, and benefits tailored to her maternity care needs. As Maria progresses through her pregnancy, the collaborative efforts between Dr. Rodriguez’s practice and the health plan ensure that Maria receives timely interventions, support services, and access to prenatal care resources. Any potential risks or complications are identified and addressed early on, leading to improved maternal and infant health outcomes.

By working in tandem with providers and leveraging the provider-patient relationship, a health plan can enhance member engagement and also facilitate proactive interventions, leading to improved health outcomes, cost containment, and ultimately, a more patient-centered approach to healthcare delivery.

Anish Sebastian co-founded Babyscripts in 2014 with the vision that internet-enabled medical devices and big data would transform the delivery of pregnancy care. Since the company’s inception, they have raised over $40M. As the CEO of BabyScripts, Sebastian has focused his efforts on product and software development, as well as research validation of their product.