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Health Plans

MA competition leads to more personalized member service

November 29, 2018
Scalable, cost-effective personalized care now possible for the Medicare Advantage population.

Every day, 10,000 Americans turn 65 and are eligible to enroll in Medicare Advantage (MA)

Currently, there are more than 2,300 MA plans available across the United States and the average senior has 21 plans from which to choose for their coverage. Needless to say, competition is fierce in the MA market, as traditional and unconventional payers bring to market new and innovative care solutions for this rapidly growing member population.

To keep pace, payers are moving beyond traditional delivery models and seeking innovative ways to better serve members and meet their healthcare needs, such as:

  • More effectively and efficiently managing chronic conditions
  • Improving quality of care
  • Closing gaps in care
  • Developing effective and efficient workflows
  • Delivering member service that’s personalized to healthcare and lifestyle needs

Salud Health’s high-touch concierge approach

Let’s look at the story of one payer I’ll call Salud Health Plan,* which created an MA plan featuring a high-touch concierge approach to help members coordinate care. Many members have three or more chronic conditions often managed by different providers. The plan assigns each new member a member advocate, typically a social worker who establishes a long-term relationship with the member. From the plan’s perspective, this means more satisfied members and higher Medicare Star ratings. For the member, it means having a single point of contact for all of their questions and concerns.

Initially, Salud member advocates called members at the outset of the member’s relationship with the plan and spoke with them about their health and care. While members responded positively to the outreach, the plan determined there were many opportunities for improvement.

The plan found member advocates:

  • Were not connecting with enough members each day
  • Did not have access to the member’s record and relevant health information when calling
  • Were not aware of members’ social determinants of health (SDoH) such as transportation, food insecurity or isolationism
  • Missed care opportunities and other priority care for members with critical needs

Fortunately, MA plans like Salud can use a proven population health management (PHM) solution like Geneia’s Theon® platform built on Salesforce’s industry-leading customer relationship management (CRM) platform and partner ecosystem to provide:

  • Workflows that fully leverage data and make staff more efficient and able to touch more members each day
  • Prioritization to ensure the neediest members receive critical services first
  • Access to member records while on the phone with them
  • Social determinant of health information to address needs outside the clinical care setting
  • Access to advanced data and analytics providing the ability to close more gaps in care than traditional methods
  • A meaningful improvement in the quality, satisfaction and utilization of care for their members

Member advocate Mike uses the Theon® platform to prioritize and personalize member outreach

Let’s look at how Mike,* a Salud member advocate, uses the Theon® platform to support his members and address the deficiencies outlined above.

Each morning, Mike logs into the Theon® application and selects patient/member information. There he sees a list of assigned members and runs a member report stratified by risk. At the top of the list is Josie*, a newly assigned member with congestive heart failure (CHF), diabetes and hypertension. Mike can see Josie has a high future predicted cost and high risk score. Given her diagnoses and predicted risk, Mike knows she will benefit from immediate intervention.

Mike sees Josie recently visited the emergency department and was admitted with a diagnosis of congestive heart failure. He also notices she missed her last two appointments with her primary care physician and her latest appointment with her cardiac care specialist. Mike knows she is at risk for readmission to the hospital if she doesn’t receive the right care. Mike also notices an alert for the possibility she may have missed her appointments because she doesn’t drive or have access to reliable transportation.

With her health record in front of him, Mike calls Josie and talks with her. He learns she relies on public transportation and the nearest bus stop is three blocks away. This has been the reason for her missed appointments and also makes it difficult for her to pick up her prescriptions. Mike is able to document in the Theon® application all he has learned during his conversation with Josie.

Incorporating SDoH into member advocacy

Mike refers Josie to a local social services agency that provides free transportation to and from medical appointments and works with Josie and her providers to have her prescriptions mailed to her residence. Thanks to Mike’s interventions and personalized support, Josie is taking her medications as prescribed, hasn’t missed any other appointments and has not needed to visit the emergency department for more than six months.

Member advocates can now step beyond the role of a traditional care manager by making social services referrals on behalf of their members. Studies show 80+ percent of an individual’s health outcomes are determined by what happens outside of the clinical care setting. So, addressing SDoH is critical to managing chronic illnesses such as heart failure and diabetes. Typically, member satisfaction improves too.

Many MA plans want to create a high-touch model like the one used by Salud Health Plan. As Salud learned, it’s challenging, if not impossible, to cost-effectively scale a concierge model without a robust, comprehensive, combined PHM and CRM solution like the Theon® platform built on Health Cloud.

*Salud Health Plan, Mike and Josie are fictional and not intended to represent any specific organization or people. This information is provided for illustrative purposes only.