A health plan’s success rests in 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 them. 

And yet health plans struggle to close the loop on engagement for various reasons, especially with Medicaid enrollees. Regulations prevent health plans from sending certain types of communication to members or limit the frequency, and lack of a relationship with a health plan decreases the likelihood that a member will engage with a communication even when they do receive it. 

This is where care collaboration can make a big difference. A member is much more likely to engage with a communication from a trusted care-provider, 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 provider-patient relationship, health plans have the opportunity to reach the member in a way that positively impacts their health and potentially their costs. 

[Read more: Babyscripts and Care Collaboration]

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 healthcare 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 may 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 may 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 where 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 their 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. 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 final outcome or perhaps prevented it altogether. Preventative 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: pregnant Medicaid member, Maria, has recently discovered that she is expecting her first child. Maria 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, Maria attends her prenatal appointment with Dr. Rodriguez, where 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 may 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 has the opportunity to 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.

Interested in learning more about engaging under resourced populations? Watch the webinar with Babyscripts and Variety Care, on Oklahoma-based FQHC, for a discussion on the strategies, challenges, and opportunities in maternal digital health at federally qualified health centers; including engaging a diverse patient population and driving enrollment across sites. 

Q1 2024 Webinar (Twitter Post) (1)


Submit a comment