A Phased Approach to Next-Generation Member Engagement

At our company, we define next-generation member engagement in terms of what health plans need to meet members where they are with a personalized experience.

The first component is a holistic, 360-degree member view of human and digital interactions, recent clinical and non-clinical touchpoints, open care gaps and recommended actions or interventions to best support member health or experience.

Next is the ability to identify and target higher risk, higher cost and impactable members to educate them on available services and support.

Also necessary is the presentation of clinical opportunities, e.g., patient alerts, care gaps, utilization patterns such as inappropriate emergency department usage.

What’s needed next are analytics to close gaps in care and scale population health management.

Then come role-specific views and dashboards to track goals and drive desired action. Roles include health plan member services representative, health plan care navigator, health plan care/case manager and provider office medical assistant.

Another important component is an understanding of consumer behavior and desires for healthcare.

Lastly, there are the collection and analysis of data on engagement effectiveness with a focus on what works and what does not for which populations.

Many health plans want to create next-generation member engagement, but struggle with knowing how to start. To help a payer evolve to next-generation member engagement, we emphasize the need for a phased approach.

Expected outcome include the ability to reach a larger percentage of the population and make a greater impact on the members who need the most help; increase member engagement rates; generate more program referrals and participation; and deliver a more personalized and tailored experience to more members.

Phase 1: Discovery and Population Analysis to Identify Target Populations

Works begins with discovery to understand current state with a focus on:

• Structure and focus: Population managed, lines of business, clinical programs/offerings, team structure
• Roles: Key clinical and non-clinical roles, number of resources, management structure
• Workflows: Standard care management workflows, clinical assessments/templates, case prioritization, member communication methods
• Quality: Quality programs, program successes and barriers, measures/metric prioritization
• Engagement: Definition, measurement, engagement tactics/strategies
• Systems: Documentation system, system integrations
• Performance: Reporting, frequency, successes and opportunities
• Vision: Program goals, success measures, barriers to success

Next, payers must analyze target population to establish baseline and identify opportunities, utilizing a state-of-the-art platform. A platform should integrate risk scores, demographics, hundreds of algorithms and clinical markers, gaps in care, as well as scientifically validated, clinically approved predictive models and proprietary identification and stratification methodology to automatically categorize every member into one of four risk categories: healthy, rising risk, chronically ill and catastrophically ill. 

Then, payers should identify 2–4 use cases to improve quality, utilization and/or cost, otherwise known as the low hanging fruit, such as:

• Quality opportunities: Members who are due for preventive cancer screenings such as colorectal cancer and breast cancer
• Utilization opportunities: Members who have not seen a primary care physician in the past 12 months or frequent ED visits, members who have visited the emergency department two or more times in a six-month period
• Cost opportunities: Members who are using specialty services for services that can be obtained in lower-cost settings, utilizing out-of-network providers instead of in-network providers, costs incurred by unnecessary services such as labs, radiology and avoidable emergency department visits.

Phase 2: Develop, Deploy and Measure Effectiveness of Engagement Strategies

Payers must develop engagement strategy for identified cohort of members, considering each of four risk categories: healthy, rising risk, chronically ill and catastrophically ill. For example:

• Outbound Combined with Inbound: Healthy members who are due for a colorectal cancer screening are digitally-engaged with email and text reminders. An alert about the open care opportunity is added to the member records for this cohort and member services representatives are empowered to advise these members to schedule an appointment with their primary care physician to understand their options for colorectal cancer screening. When a member in this cohort calls member services to, for example, inquire about a gym benefit, the member services representative sees the alert and uses the opportunity to educate the member about the need for colorectal cancer screening.
• Outbound: Hypertensive members classified as stage 2, medium or high risk for a hypertensive-related complication in the coming 12 months are referred to health plan care management. Care managers outreach and engage these members to create personalized care plans that may include a home blood pressure monitor, education on the hypertension disease process, monitoring of medication adherence, and regular physician appointments.

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Lori Logan, Geneia Chief Product and Client Officer

Geneia LLC is a data science and healthcare analytics company that helps healthcare providers and health plans provide personalized, patient-centered care. Clients use our AI-driven data models, cloud-based technology, and analytic insights to identify and engage the right populations with the right care, improving cost, quality and health outcomes.

To learn more, download the white paper, Next-Generation Health Plan Member Engagement: A Phased Approach.