How to Engage Medicaid Members in Closing Care Gaps

On June 15th, Advisory Board hosted a cohort of Medicaid plans to discuss how to engage Medicaid members in closing care gaps post-pandemic. We defined care gaps as not only the list of HEDIS measures or a single clinical care gap but also addressing social needs, health disparities, and keeping members healthy in general. Specific care gaps that the cohort members said they were especially focused on this year included:

  • Covid-19 vaccines
  • Early childhood and adolescent immunizations
  • Wellchild visits
  • Women’s health visits
  • Prenatal care
  • Diabetes screenings
  • Behavioral health visits

Care gaps are top-of-mind for these Medicaid leaders because of the impact on member health outcomes but also because of the meaningful financial consequences. First, leaving care gaps open can lead to downstream ED utilization and consequently hospital inpatient stays. Second, many managed care organizations (MCOs) have bonuses at risk based on their quality scores. Third, select plans can be fined from the state based on quality scores—or even removed from auto-enrollment lists which hits membership growth and revenues.

Covid-19 has made closing gaps even more difficult for health plans as they grapple with increased enrollment (from lack of disenrollment), care avoidance, exacerbated social needs, and the spotlight on health disparities.

Covid-19 has made closing care gaps even harder


Even telehealth, which increased access across the country as it gained popularity during the pandemic, was not as widely adopted in the Medicaid line of business. Our Medicaid plan leaders commented that their telehealth rates were lower than expected because providers weren’t coding for them, members were using phone calls rather than virtual visits, and members (even in urban areas) struggled with broadband connection. Behavioral health services saw the highest maintained spike in telehealth growth, as we have seen in other lines of business.

As for what plans are doing to close care gaps, Medicaid plans consistently indicate they are looking to the primary care physician (PCP) as the front door, or entry point, to the health care system. PCPs are naturally viewed as the ideal front door because they are trusted by patients, see many members every day, and can close multiple care gaps in a single encounter.

PCPs are often the ideal entry point to close care gaps


However, not all members see a PCP on a regular basis. Said differently, our ideal front door may not be the member’s ideal front door. Members might not be able to find a location or time that’s convenient because select PCPs don’t see Medicaid members because of lower reimbursement rates. Simultaneously, certain members don’t trust doctors or the health care system in general. Lastly, even if members have access to a PCP, they may not see the value in preventive care.

Why some members don’t think PCPs are the ideal front door



In this instance, being in the Medicaid market may be an advantage. The localized Medicaid market offers the unique opportunity to work with more front door options from the community. If plans really put the member in the center, many more touchpoints exist and potential front doors expand the often-overburdened PCP front door.

While plans’ provider relations and network management teams are addressing structural challenges such as lower reimbursement rates and slow movement to risk-based contracting, plans’ member engagement teams can help in the near-term by expanding front doors through member engagement and community partnerships.

How plans can expand front doors through member engagement and community partnerships


First, plans can identify the ideal front doors for members rather than trying to change their members’ preferred front door. Second, plans must upskill trusted community partners because community-based organizations (CBOs) are good at their jobs—not yours. Third, plans must tie care to pre-existing relationships so the value of preventive care to resonates with members.

Sample action steps your plan can take to advance each of these goals

Identify ideal front doors

  • Don’t assume you understand all your members and their wants
  • Set up focus groups of different member demographics
  • Create processes to collect member feedback before new initiatives
  • Share complaints in the call center with plan employees who make changes to network, product design, etc.

Upskill trusted partners

  • Create value-based contracts with CBOs
  • Measure your access not just by days to appointment but also days to appointment with someone who looks like the member
  • Train community partners in health care knowledge
  • Update hiring protocols to increase internal diversity

Tie care to relationships

  • Highlight how preventive care impacts relationships in marketing scripting
  • Use traditionally social events for care education
  • Incorporate human behavior into ROI calculations
  • Create outcomes-based incentives for providers
Download the takeaways
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