Jun 4, 2019
Effective Medicaid engagement strategies encourage member populations to take a more active role in their healthcare. Done well, member engagement can help payers improve population health and plan performance. But that's easier said than done. Indeed, member engagement is one of the biggest challenges faced by plans and providers.
While there's no silver bullet to maximizing enrollee engagement, there are several proven strategies and practices that can help address mitigating factors such as social determinants of health, wellness motivators, and ineffective member communications.
We invited Natalee Fowler, a nationally recognized expert on Medicaid member engagement, to share some of her favorite techniques for helping payers better engage members. Natalie covers the common challenges, unpacks the buzzwords, and provides a roadmap for a contemporary communication strategy that can help payers raise the bar for engagement.
On today’s show, we discuss:
KESLIE: Good afternoon everyone. My name is Keslie Crichton. I’m VP of Business Development for Change Healthcare’s Member Engagement and Dual Eligibility Solutions. I’m here today with Natalie Fowler, subject matter expert and consultant for Change Healthcare with years of experience working on finding better ways to engage members. Natalee, we’d like to talk with you today about how we can better engage healthcare members. But can you start by telling us a little bit about yourself?
NATALEE: Good morning, Keslie. Thank you so much for having me join you today and talk about the ever increasing challenge around healthcare consumer engagement. I’ve worked with health plans, provider groups, and technology companies for the past 16 years to solve this very complex issue and I’m always looking for the next silver bullet.
KESLIE: Thanks, Natalie. That’s a great segue into today’s podcast from Change Healthcare’s Member Engagement Team. At Change Healthcare, we have dozens of solutions and hundreds of engagement topics in our content library. We touch members in all different ways, claims, EOBs, premium provider payments, also just looking for ways to communicate with members about their health, wellness, and eligibility into various programs. We’re always looking for ways to increase that engagement rate, improve the members’ experience, but also to provide efficiency and results to our payers. Why does this have to be so hard and so challenging?
NATALEE: So I think the main challenge is really what we’re trying to do is fit a square peg into a round hole. Or another analogy is that we’re using a peanut butter and jelly approach for everyone. So as an example, Keslie, what’s your motivation to stay healthy and what’s the best way to engage you?
KESLIE: Well I guess my primary motivation would be just to keep up with my son. So, he’s a teenager so I’m always struggling to participate in the sports that he does and that he wants to practice. But, also, I’m really encouraged and incentivized by the company’s incentive program to lower payroll deductions. So that works for me. As far as how to communicate with me, if you want to reach me, a text message is the beast thing. I am always on the phone, like all day long. So calling me or expecting me to listen to a voice mail is really slim to none. And my inbox is full of email messages, and so just text message is the best.
NATALEE: Right. And so for me my motivator is to be as healthy as possible so I can continue to scuba dive all over the world. And I prefer email communication. However, attitude versus behavior, email is my preferred but in terms of behavior you’ll always get an immediate response when you text me.
KESLIE: I want to trade my motivator for yours and go scuba dive all over the world.
NATALEE: Come on. Let’s go. So health plans, providers, and technology companies really need to recognize that everyone is different. Everyone has different health motivators, everyone has different modality preferences, and being able to recognize that is the only way that we really can move the needle in scale and, more importantly, looking at that and being able to make those insights actionable.
KESLIE: So I’m guilty of this myself, I use the word “actionable” all the time and I think it’s become one of those industry buzzwords. What do you really mean? How are we going to deliver on that action?
NATALEE: No. You’re absolutely right. It definitely is a buzzword and it is something that we need to if we’re going to use it we’re going to need to deliver on it. So what does it really mean? Well what it means is designing a consumer engagement campaign. And that campaign needs to take an approach where first we need to look at the target audience, identify the attributes of those individuals, and you would ultimately would use the analytics to be able to do that. So after identifying the attributes, you’re then going to segment them. And now you’ve got clusters of people that look like one another, that have similar income brackets, race, ethnicity, age, etc. So from there, we can also start to look at what their health motivators are, in addition to–if we don’t have sort of preferred method of communication–we know that a younger generation is going to be more technology apt in using text messaging and email versus an older generation that would prefer to use mail and sort of a live agent type call. So understanding who you’re going to outreach to, what those attributes are really starts with the first point of designing that communication program. But more importantly, once you understand their preferred method of communication just as I’ve said I’m guilty of it, my preferred method is email yet I immediately respond to a text. So being able to understand the individual’s preferred method of communication, then delivering on it. But more importantly, actually being able to measure to see if they’re actually taking action on it. And that in itself is a very complex campaign, it’s to the highly dynamic, and the only way to really achieve that is going to be through scalable technology such as Change Healthcare, you guys have your Smart Connect platform. It’s an omnichannel communication platform that I understand can communicate to millions of members a day.
KESLIE: Right. And absolutely. And we do often look for members that have chosen a preferred mode of communication simply because it’s the easiest to ignore. So you do have to continually look at did they not only read the message, but are they following through and actually coming through with whatever the engagement topic might be. So those are all great points, Natalie. I want to shift gears just a little bit and become a little bit more focused. Can we chat about maternal health?
NATALEE: Absolutely. What do you want to talk about?
KESLIE: Well, it’s a growing area of focus for our payers and providers due to I think two things. The rising cost of NICU hospitalization, and recently for the past couple years our rate of pre-term births in the U.S. has increased again and is now over 10%. So for many, many years it was down and for the past three years it’s gone back up again. In my experience working with several of our regional plans and our national Medicaid plans especially, they’re trying to solve for three things. Related to that, they want to lower their NICU rates and their pre-term births. So improve the members’ health and the mothers’ health and the babies. They want to improve their prenatal visits, get members in sooner. And why? Because that’s often a HEDIS or a state P4P measure that helps become one of their revenue drivers. And they also want to use technology effectively to increase staff efficiency. It’s expensive to have nurses dialing out trying to reach members. So find solutions that can help members in an automated way raise their hand, identify themselves as high-risk, and engage on an inbound basis with that staff. So in your opinion, how can we create awareness to improve those engagement rates for those programs so we can move the needle on these metrics because that’s really what it’s all about is how do we get a hold of that member sooner?
NATALEE: Yep. Yep. That’s very true. And in fact, I was just reading a news article that really sort of reinforces the fact that engagement is challenging and we need to kind of think out of the box of different ways to engage members. And so just reading this article, United Healthcare is making investments into affordable housing projects. They’ve been doing this since 2011, and they’re actually providing housing for individuals, low-income individuals. Getting them housed, getting them stabilized, and then following through and being able to provide those care services for those individuals. So I think first and foremost it’s thinking out of the box, looking to identify where those members and solving some of those.
KESLIE: That’s a great point and we always try to encourage our clients to utilize and integrate our community advocate program with all of our engagement because it is that live touch that can help members overcome social determinants of health, and remove barriers to care but also be very member-centric with what their needs are right then and there.
NATALEE: Right. But I also think to go back to some of that, how do we create awareness to improve the engagement rate? So to me, when I’m presented with that problem by a health plan or a provider group, or even the technology companies that I consult with, it’s about looking at how do you solve that problem and I see that can be done through a campaign. So in this example, what are we trying to solve for? We’re trying to solve for identifying high-risk pregnancies. And then being able to reduce the NICU readmission. So first, I’d start by asking clients what we do know about maternal health? What do we know? So we know the target audience are females. We know most of them are under 40. They’re of all nationalities and various income levels. And that they’re all at very different stages within their pregnancies and also have very different health statuses. We also know that zip code and race play a big role in pre-term birth rates. So it’s taking that information and figuring out how do we communicate and engage those individuals if we know that everyone is very different, different attributes? In addition to that, I think that plans need to also think beyond just the HEDIS measures around pre and postnatal rates. And that’s what typically we see today. But, as you mentioned earlier the pre-term birth rates in the US has increased 10% now. Plans need to move beyond looking at pre and postnatal visits and start really addressing the complex issue of identifying high-risk pregnancies, helping females have a healthy pregnancy, and again it won’t be on the HEDIS measures. So I think one of the best practices here really is know your audience and who to communicate to.
KESLIE: Absolutely. I totally agree with that. And we’ve deployed best practices in our maternal health program I think little by little over the years. We’ve evolved. So we introduced text messaging and we see a large increase in that. We use it effectively to remind people to take certain actions or appointment reminders reminding them to schedule their appointments if we’re not doing it on their behalf. Email and web-based portals and tools can also be really effective. Email is not often secure, but an email can send them to a secure web portal so that you can engage information about the health status about pregnant mother or whatever other disease campaign that you might be doing. And then distribute also, health content and education. So we recently did a complete overhaul of our smartphone app. It’s available now on both Android and iPhone and we’re seeing a large uptick of members using that as their preferred mode of education, which I totally makes sense because I mean it was a long time ago that I was pregnant but you want information when you want it. Not just between business hours. When you can’t sleep and you want to read about gestational diabetes to see if you have any warning signs, that might come at one or two o’clock in the morning. So the smartphone app is really I think a great tool for certain populations. The text messaging reminders, the emails, we still have IVR, so I think you really still need all modes of communication. But over time, especially with this population, I think we’re going to see more and more move to that smartphone app.
NATALEE: Yeah. And I would agree and just looking back at historical programs that I’ve worked on, the commercial population defaults to wanting to use email. And as that generation gets younger, now we’re going from email less popular modality, now moving to text messaging and now even some text messaging going by the wayside because everything is now app. And I think we were just talking earlier this week and I think you told me that on average, we touch or pick up our cell phones 52 times a day. Was it something like that? So that was a great lead in for me for my second best practice which was around modality. So it’s recognizing the preference of those modalities and being able to execute on that. You’re going to get a higher engagement. But establishing the ability to measure that impact and also measure the if someone isn’t engaging with their preferred method of modality then being able to switch it up to deliver that content in an alternative mode. I said earlier, email, but text message. I know that I can ignore email. So being able to deliver on an alternative mode to get them engaged, this is a great example of attitude versus behavior. And then I think the next is develop engaging content to ultimately maximize the same engagement.
KESLIE: I think that’s a great point. So what I think that you mean by that is in the case of maternal health, it’s got to be just patiently correct. It’s got to be relevant to the person at the right time at the right place that they’re receiving that message. Do you have other ideas around that?
NATALEE: Yeah. So if we just sort of look at your maternal health program you just said that you’re delivering content based on gestationally correct content for each week, but you’re using imagery. You’re using health literacy to do that. So it’s really important, again understanding those individuals, making sure that you’re using images to help individuals associate themselves. That’s me there. I am that person. Make it personalized. I think the other thing that we all fall down and really don’t do a great job collectively as health plans is recognizing that we want data from our members and we collect this information. And for the most part, we’re willing to give that information to the health plan. But I think we all need to do a better job at when we’re asking that is deliver information back. So as an example, if you are asking a female as part of your maternal health if they’ve been to their most recent doctors appointment, and when they turn around and say no you should be able to respond back with a very personal message about the importance of attending those regular prenatal visits to ensure a healthy pregnancy. On the reverse side of that is for the female that is keeping up on those regular appointments, celebrate that success. Reward that individual and keep them motivated to do that. And one example would be perhaps provide an image of her baby at that gestational age so she can associate this is my baby, this is the work collectively we’ve done together in maintaining a healthy pregnancy.
KESLIE: Those are all great points. I think one of the prime examples that is also relevant that comes to mind that everybody can kind of understand because it still applies to everyone unfortunately is with smoking. One of those big questions that you ask a pregnant mother is, are you a smoker? So if they say no, you don’t want to educate them on how to quit smoking, but you do want to warn them about the dangers of secondhand smoke. So collecting again, to your point, collecting the information and then using it effectively to continue that communication.
NATALEE: Right. And then I think also it kind of goes back to even how those words are written to actually ask that question. So I know I go to my doctor for my annual PCP appointment and wellness visit and I’m always asked how many glasses of alcohol do I consume? And I would say maybe one glass of wine, but sometimes maybe two, maybe three. But I feel like I might be judged if I say that I’ve had one or two more. So again, it’s all in how you write that information, those questions for someone to be truthful, to allow that female to say and put her hand up to say, yes I do smoke. So again, it’s not only writing the content from a health literacy perspective so they understand it, but write it in an engaging way that people don’t feel judged and want to freely share information with you.
KESLIE: Those are really good points. Thank you. So I think performance over time and applying best practices is other areas that we really need to define success on. You’ve talked about the measurement of these things and setting the stage up front. We talked about what my health plans and my maternal health programs are really targeting. Staff efficiencies, preterm birth rates, lower NICU days, their HEDIS measures, all of those things. But what do you do with those metrics once you’ve started measuring them? I wonder if they’re not as great as you expected? Like how do you keep moving the campaign forward?
NATALEE: Right. So that’s a great question. And it’s always presented to me as a consultant right at the very end. The program ends, and they look at the results and it’s oh, it really didn’t achieve or are these good results? That’s always the great question. Are these results any good? Okay. Well what did we define right at the beginning? And too often plans make the mistake of not defining what success looks like and how they plan on measuring that. So I think it’s establishing those clear metrics. But also, it’s looking at digging into the data and looking at what really works. So technology today, just like the Change Healthcare Smart Connect platform does have the ability to do A/B testing. So again, we talked about earlier how your health motivators are very different from mine. If you send to me a letter to talk about getting my annual wellness visit and you’ve got a scuba diver on the front of the image I’m going to associate that with that’s me and I need to keep up with my health visits so I can keep diving all around the world. But it’s measuring to see whether I’m really responding to that. And if I’m not, then it’s changing it up. Now I know that we work, many of our plans work in the government market and so we have to have not only CMS approval but state approval. So how do you overcome and be able to implement an A/B testing strategy when you’re working with government programs? So what I recommend clients do is at the beginning of the campaign is actually create two flavors of the content. So flavor A versus flavor B. And even try to create several more flavors of that for each of the segments. But ultimately at a minimum, two flavors, A and B. And then to overcome the ability of meeting states’ and CMS approval is submitting that information ahead of time. Getting approval so that if you need to make a change it’s there versus oh, it isn’t performing I need a plan B. Write plan B. And then be waiting 30, 60, 90 days approval before you can make any changes. Planning ahead you’ll be able to adjust on the fly.
KESLIE: Those are really good suggestions. I like the idea of submitting multiple campaigns or treatments to our campaigns up front for both content delivered via an automated call campaign, emails, text messaging, and so forth because we know that different members respond differently. We see this in our own outreach campaigns especially on the Medicare Advantage that we’ve done for a lot more volume and for a lot longer, that certain ways of even asking a question or making statements are more credible and valid to some of our members. So I think those are really good ideas. Do you have anything else to add as far as best practices for overall engagement or maternal health specifically?
NATALEE: I think one area that we haven’t talked about yet is that pulls into that measurement area, again if somebody isn’t responding having the ability to look deeper into the campaign and follow the member along that journey and identifying that if they’re not engaging, perhaps they engaged, they were excited about their pregnancy, and so they engaged the first few weeks maybe even the first few months but then they start to tail off. How do you identify if someone is starting to become unengaged? How do you identify that and be able to make a change? So again, another sort of good practice is build in a measurement tool or process to be able to identify that and then being able to deliver or sort of nudge communications. So you’ve got your overall content delivered week by week, different messages. But then overlay that with nudge communications when you have the ability to see that Keslie isn’t engaging. Give her a little nudge and we now know that the text message is going to be the best way to engage Keslie.
KESLIE: Right. We recently had this conversation with one of our clients about use of incentives. You don’t want to pay somebody to do everything that you want them to do. That could get a little bit expensive. But sometimes a cash incentive or a financial incentive is worth it depending on what you’re trying to engage them to do. But oftentimes, we are using our social advocacy programs, community app kit really effectively to be that inventive. So because it can offer valuable financial incentives for programs that could be a free cell phone or lower their utility bills, or help them get a backpack program for their kids, there’s all sorts of valuable programs in there that often engaging them I think and giving them something that’s important to them that improves their lifestyle works the same way as an incentive. It might just make them feel a little obligated to follow through or it might be really valuable and just create that brand awareness and brand loyalty that you need to get them to follow through. But either way, are there any certain metrics or actions that you think, a cash incentive or a real financial incentive is worth applying it to?
NATALEE: I definitely think incentives can work. I’ve seen programs where for example, a diabetes program we used a diabetes cookbook that was the incentive and people were signing up. If they engaged in the program and they hit a certain milestone, they received a diabetes cookbook, recipe cookbook. So it doesn’t have to always be cash. I’ve seen health plans improve their pre and postnatal rate by doing community baby showers. So again, everyone’s different. A $20, $50 incentive isn’t going to drive me and motivate me to get my annual wellness visit because there’s lots of studies out there trying to figure out what is that magic number. We both have done work with health plans around the ACA, trying to get them to fill out health risk assessments. I’ve heard as much as $200 as an incentive just to ask someone to fill out either a paper or web-based survey.
KESLIE: I would do that all day long.
NATALEE: So the motivators are different, which is sort of that underlying theme here of today’s podcast. How do we engage people? It all stems back to trying to figure out what motivates Keslie, and what is that message to her? How do we keep her engaged along the relationship with the health plan?
KESLIE: Well, Natalie, thank you so much for your thoughts today and we hope you’ll join us again to discuss other ideas whether it be about maternal health or other chronic diseases or just ways for health plans and providers to engage their members more effectively. We really care about members having the education needed to make good healthcare decisions in the long term. So be on the lookout for other topics coming soon on ways to improve quality and risk-adjusted revenue by Change Healthcare. Thank you.