Podcast: Welcoming, onboarding, and retaining members in the new year

A new year will soon be upon us, bringing a flurry of health plan activities with it. This includes new member welcome and onboarding, transition of care support, primary care provider (PCP) assignment, and generally making a good first impression to help ensure member satisfaction and retention. In a new podcast, Anne Davis, Cotiviti director of quality programs and Medicare strategy, joins Jennifer Forster, director of Medicaid strategy, to discuss:

• How to support new members joining Medicare Advantage and Medicaid plans in 2022
• How to optimize health risk assessment (HRA) completion
• How member retention impacts plans
  

Podcast guests

Anne L. Davis has spent the last 20 years focused on healthcare quality, program development, and evaluation. As director of quality programs and Medicare strategy, she helps ensure that Cotiviti products support clinical outcomes improvement. Anne has subject matter expertise in the Medicare Advantage market, Star Ratings, HEDIS^®, and NCQA accreditation standards.

Jennifer Forster is responsible for developing and implementing Eliza’s Medicaid offerings and sales strategy. She previously worked for Tufts Health Plan where she served as the product director and operational contact for Tufts’ government-sponsored business. As the director of public partnerships, she led a team that supported contract management activities including compliance, reporting, communications, and negotiations.

Podcast transcript

Why is the welcome and onboarding process so important?

Anne: I think theoretically, we all know that the first touch with the health plan is really crucial because it sets up the relationship with your membership for the rest of the year, so those first touches make a really big impact on your membership. So things like your pharmacy prescriptions, making sure that they're a seamless transition from whatever health plan the person had been using before to your new health plan. It's also a really good time to understand the needs of your population, so performing a health risk assessment, also called an HRA, is a really great opportunity at the beginning of the year. The other thing that's specific to Medicare Advantage is that in the first three months of the year, beneficiaries have an opportunity to leave the plan that they've chosen and choose another plan. So that movement in the first quarter is another reason why we want to make sure that that first touch is really impactful and positive.

Jennifer: For Medicaid it's similar in that you only get one opportunity to make a good first impression. Also, HRAs are required within the first 90 days to be completed by the health plan; it's a great opportunity and requirements to get that done. But what differs with Medicaid from Medicare is that unlike with Medicare and that rapid enrollment period within the first quarter, Medicaid enrollees are enrolling and enrolling throughout the year. They have choices just as they do in Medicare Advantage, but they're not locked in to that choice in most states.  In some states they are, but the majority of Medicaid enrollees can vote with their feet and they can leave at any point during the calendar year to switch to another plan. So if that welcome in onboarding process doesn't go well and they're dissatisfied, they can pick up and move to another plan within their service area. And oftentimes there is another that they can choose from, so satisfaction plays a really important role.

There's also the issue of just onboarding people, giving them an orientation to their new benefits in many cases. This could be somebody's first exposure to health insurance, and so health insurance literacy may not be that great, and it's important to really help people understand how to use their benefits and when to use them, and the role of a primary care clinician or a PCP. A Medicaid enrollee is automatically assigned a PCP if they don't come on to the plan with one already, and most of them don't. So that means that I think upwards of 75% of people are auto-assigned a doctor in their area based on a number of matching criteria, including language and geography. But oftentimes the members don't have an established relationship with that PCP. They may have seen another PCP in the past that they feel more comfortable with. And most of the calls the beginning of the month to a Medicaid plan are to ask questions about who this PCP is on their ID card. It's usually somebody they don't know, and one way to drive call volume down and to help with member satisfaction is by proactively reaching out to them during this orientation period and inquiring about who their PCP is and if they have one that they work well with. And then so if it's not somebody they're already assigned to, getting them as their PCP on record, so that goes a long way in building trust and satisfaction within the membership.

How do you recommend supporting new members coming onto the plan in 2022?

Anne: So I think I'll tack on to what Jenn just spoke of in terms of new members and when new members come to any health plan, they need to understand what the benefits are, when to use them, the importance of proactively engaging with those members. So I think that's the same across the board. What's special for the Medicare Advantage population is that older average age tend to have more prescription medications, tend to have more chronic conditions that they're managing, so focusing that first touch and that entrance to the health plan around creating really positive care transitions—so if the member needs to change their prescription medication or perhaps their specialist is no longer in-network under this new plan, having the health plan really focus on those cohorts of members who really need to interact with the plan earlier in the year and for more specific reasons. Connecting them with care management or disease management programs, connecting them with any durable medical equipment that they might need is really, really important again during that first couple of months of the plan. I think I'll also echo what Jenn said about making sure to proactively reach out and engage your new members. It's really critical for Medicare Advantage members, of course, because CMS requires a welcome to Medicare visit with their physician, and that has to take place really quickly upon enrollment into Medicare Advantage plan. So making sure that you're reaching out to people quickly, like within two weeks of the beginning of the year, is really essential again to set up that relationship for future success.

 Jennifer: And then from a Medicaid standpoint, I think 2022 is going to be a unique year, although not entirely unique from 2021. But I think my point is that in 2022 as new members are onboarding, it's going to be important to really it's always important, but it's going to be really important to make sure those HRAs, those health risk assessments are robust and completed. And so don't just ask the standard HRA questions, but it's important to ask about those social determinants of health or SDOH, socioeconomic barriers to care, because so much has changed in 2021 and 2020 and a lot of people coming on to Medicaid are doing so because they may have experienced a COVID related job loss. People may have had COVID themselves and could still be dealing with long-COVID symptoms. That type of information is really important to understand.

And just the nature of the last year and a half in itself, it's important to ask people how they're doing. Are they experiencing increased anxiety or depression? Are they socially isolated? These types of things are really important because they have a big impact on your health, and health plans want to know how they can help and where people need assistance. And when you're a new member, they don't have claims data to fall back on. So it's really important to have those one-on-one conversations with their membership so that they can determine where they might benefit for some extra help. It might be care management services or social care management or connecting members with resources in their community. And then the other thing on Medicaid—that I think is probably important for Medicare as well, but a little more so on the Medicaid side because that population tends to be more transient—especially again, given the last year and a half that we've had with a lot of change in people's job status and economic status is getting up to date contact information and making sure that member knows that they need to keep that information up to date with both their plan and the state so that they don't lose coverage when it comes time to renew.

What advice do you have for plans looking to maximize health risk assessment (HRA) completion?

Jennifer: I think most plans struggle with this. It's difficult to get people to complete a health risk assessment, particularly when it can be lengthy. But what we really recommend is taking a multi-channel approach. So don't just send them a letter in the mail with a big survey to complete, try reaching them where they are. So that means, you know, catch them on the phone. Or if you know that they are maybe a younger population that's more text-based, send them a text message with a secure link for a personalized URL to complete it at their leisure, either on their phone or their device or their computer. Offer it also through perhaps your member portal. We really think that you can't just use one size fits all. You have to kind of hit them in a couple of different ways in order to maximize your completion rates. Another thing that a lot of plans use, and it might be more relevant for the Medicare population, although it really depends on your approach, is using incentives. So maybe you get like a gift card or something like that if you complete your HRA. And then the other thing that we've seen is to tack it on to the welcome outreach. When we analyzed these, we found a 2% to 3% higher rate of completion when it was included in a welcome and onboarding outreach. I think that's probably because you're reaching them right at the beginning of their enrollment, they're eager to make sure that they're covered, what’s one more thing asking them a few questions or prompting them to complete an HRA online. We find a higher rate of completion when you add it to that welcome outreach.

How does member retention impact health plans?

Jennifer: Member retention improves health outcomes, so you want to make sure that you're retaining those members that you have put all of that care and effort into over the benefit year. And part of the reason is because of quality improvement and HEDIS, which are quality improvement measures, standardized measures that require continuity of coverage in order for you to count them in your final score. So we spend an entire benefit year working with members and making sure that they're closing their care gaps and getting to the doctor and managing their conditions and all of that. But if they are to disenroll prior to the end of the calendar year, you don't really get to take credit for that. And then your quality improvement scores suffer.

There’s also health outcomes. Those that are continuously enrolled in a plan year over year show better health than those that are bouncing around or in Medicaid. We call that churn, coming in and out of health coverage, and you can imagine that's because if you don't have coverage for a period of time and you're managing a chronic condition or you just happen to get sick but don't have coverage, when you come back on to the plan, you're coming back on sicker or having a higher clinical risk. So those that are continuously enrolled are healthier, and it's important that we keep people covered so that they are getting all the preventive and chronic condition management care that they need. And then there's a financial aspect as well, so healthier people cost less to insure. There's also a revenue implication for health plans that are experiencing a lot of churn or on and off of the membership. We already talked about of the medical expense of sicker members and people who are dealing with pent-up demand. And then there's just the administrative costs of reenrolling members. People that come off and come back on need to go through that whole welcome and onboarding process. Again, they need a new ID cards. They need to be enrolled into care management that costs money as well.

Anne: A lot of those same elements are also crucial to Medicare Advantage plans and beneficiaries. And the differentiator for MA plans is that they are kind of rooted in quality bonus payments for providers based on quality outcomes, and that is known in the industry as Medicare Star Ratings. And so Star Ratings are based on those HEDIS outcomes or quality care gap outcomes, as well as pharmacy measures and consumer experience. So when we think about retention in a Medicare Advantage plan, we know over the last decade or so of experience that loyal members do close more care gaps, so they are healthier individuals. And they also have stronger relationships with their providers and other caregivers throughout the care neighborhood. And we also know that the more loyal the members are to a certain health plan, so they're in the same plan year after year, the more satisfied they are with the plan. So there's definitely a relationship between length of time in the plan and satisfaction with the plan and from a Medicare Star Ratings perspective, consumer experience is worth more from a weighting perspective in how the ratings are calculated, so everyone is really focused more and more again on making that experience the best for their membership—starting from the very beginning of that welcome and onboarding, but then continuing to retain those members with positive benefits, positive experiences throughout the year.

What do health plans need to consider when developing their member retention strategy?

Jennifer: Well, on the Medicaid side, it's all about churn. That's kind of on again, off again of coverage, and that could happen for a number of reasons. It might be that somebody has Medicaid coverage, but then their income changes. Maybe they get a job and they have access to employer-sponsored benefits, or maybe they make too much money to qualify for Medicaid, or they have a seasonal job or something like that. So their income is fluctuating throughout the year, which is impacting their ability to maintain their Medicaid coverage. So they come on and off. Or it could be in Medicaid, you’re required to renew your benefits once a year. That's to make sure that you're still eligible for the program. And oftentimes, people don't get their renewal notice in the mail, and we already talked about that's often because people move throughout the year. And they don't update their contact information with their plan or their state, and then they miss that notice that they need to renew, and they fall off of coverage; they fall off of care. So we actually found that 60% of people that we speak with don't have their renewal notice in hand. And that's a really large percentage and a really big problem for Medicaid enrollees, for the plans that are serving them, and for the states as well, because we already talked about the impact on health status and satisfaction and plan revenue and savings. So it's a really big deal.

And in order to prevent churn, there's a bunch of policy actions that states could take, like continuous enrollment criteria allowing people to stay on a plan postpartum, maybe for 12 months postpartum or six months postpartum. Some states disenroll six to eight weeks after having a baby. So there's a number of policy things that can happen at the state level.

But there's also things that plans can do to prevent churn. So that might include keeping their contact information updated every time they have an interaction with a member confirming their contact information, their mailing address, getting consent to outreach to members over text message and email so that they can reach them a number of different ways. Also reminding members to keep their contact information updated throughout the year, reminding them proactively about upcoming renewal periods something other than direct mail, giving them a call or a quick text, or reminding them when they need to do the redetermination process and confirm their eligibility to continue coverage on Medicaid. With COVID-19, they put a temporary hold during the public health emergency. States can put a hold on redetermination processes in order to ensure that people have coverage throughout this really turbulent time and making sure that people, are medically covered, but the public health emergency is due to end—we think probably by the end of the year and all of those renewals that were meant to happen from March 2020 through 2021 are going to be reprocessed. And so we saw a lot of growth in the Medicaid program during COVID-19, which is understandable. But now we could see the potential for a lot more churn in 2022 when they turn those renewals back on. So plans can really get ahead of that by reaching out to members now and making sure that they have that updated contact information on file so that when the state does turn those processes back on, the members will receive their notices. They should also hopefully get an outreach from their health plan as well. And like I said, use that multichannel approach. Call them, text them, email them. Don't rely on direct mail.

Anne: I think a lot of those strategies are similar for the Medicare population as well. I think probably the most important thing to consider when developing a retention strategy for Medicare Advantage is you really need to know your membership. You need to wrap your arms around the unique needs of seniors and to realize that those needs change between those who are just turning 65 versus those that are 85 and older. The second thing is that there were a lot of people delayed in getting care during COVID times, and that was certainly seen in the Medicare Advantage population as well. So as you're onboarding new members, it's a great opportunity once again with that welcome and onboarding health risk assessment to understand where are they in their care journey and do they still have relationships with a primary care provider. Have they seen that care provider in a period of time?

Jenn also mentioned wanting to ensure that we have the right contact information on file so that we can interact with people in the ways that they want to interact with us. So it might be mail for some, it might be phone calls for others, it might be texting or online portals. So again having that multichannel approach and also getting to know what your member's preferences are around the ways that they want to interact with the healthcare system. And I always caution plans: don't lump all seniors into a bucket because there is a wide range of technology acceptance within the senior population. So definitely pay attention to that as well. And of course, the last thing that I'll mention is, especially for Medicare Advantage: member experience is everything. So making sure that at every touchpoint your members feel cared for, respected, understood, listened to. So that first touch is essential, but also customer service training right across the board, from member services to your pharmacy and pharmacists. It really requires plans to do more work across the healthcare system so that they're communicating across different silos and functions. They're sharing information for the betterment of the individual. So that when a person calls in to member services as an example, member services sees that holistic view of the member, knows when they've called in last, and knows if they're involved in different care management programs. So I think those are really the key pieces: know your membership, really engage with them the way that they want to engage with you, and wow them at every turn. Let them know that you care about them and communicate, communicate, communicate.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).