Member Engagement Conundrum: 5 Issues in Medicare and Medicaid Plans and How to Solve Them

Is your plan struggling to address and improve member engagement? This is a common concern for Medicare and Medicaid plans. It’s a priority, but one with no easy or singular answer.

When member engagement is present, your plan will see better outcomes and reduced costs. And boosting it has benefits, including happier members, greater retention, higher quality scores, improved plan performance and healthier members.

Medicare and Medicaid plans seek to create, sustain and enhance engagement, but they face many complex challenges. Both programs have members that are part of vulnerable populations. These members have multiple, persistent and intermittent social determinants of health (SDOH) that keep them from actively participating in their health plan. 

Most plans realize engagement is about connecting with and encouraging members to be part of the process. That requires maintaining their motivation and making things convenient. Most approaches to solving engagement problems still emphasize the individual initiating interactions, and any plan can agree that this approach is not very effective. 

So what is effective? What is an innovative approach to an old problem? Those are big questions that don’t have simple answers. We will provide insights and strategies that look beyond the standard and into the new horizon of patient engagement. 

Before you attempt to improve something, you have to define success and failure. That’s why it is critical to determine what engagement and disengagement look like. 

Ideal engagement: Connective and collaborative

The most critical component of engagement is that it’s bidirectional and collaborative. Members, plans and providers are all on the same page, working harmoniously to meet the member’s total health needs. For that to occur, all stakeholders have to participate. 

Engagement is also something you can measure and track. It’s not an abstract principle built on assumptions or a conclusion made using standard health metrics. 

Unfortunately, engagement is slipping, possibly due to the pandemic. The J.D. Power 2021 U.S. Medicare Advantage (MA) Study made this clear.

Customer satisfaction increases, but engagement falters

The good news in the J.D. Power study is that overall customer satisfaction continues to increase. However, that likely won’t be a continuing trend if plans don’t address communication and engagement. Only 55 percent of MA plan members actively managed their care in 2021, decreasing by 9 percentage points from 2019. 

MA members did note some improvements in communication and information access, but in 2021, it was the lowest-performing factor in the study. The report does suggest a correlation between engagement and satisfaction. When communication between plans and members was strong, member satisfaction rose 54 points.

There is one other promising nugget in this study. Seventy-eight percent of members registered for their plan’s member portal, and two-thirds have logged into it. Portals are a key component in engagement, providing a centralized source for benefits information and other resources that can help members. 

However, the consequences can be dire for members falling through the cracks and existing in a state of disengagement. 

Disengagement leads to negative health outcomes and higher costs

When members don’t “show up” for their health, it can be devastating. A plan can certainly do all the standard things to create engagement—communication, follow-ups, resources—but that doesn’t mean everyone will respond. 

Again, a lot of disengagement ties to SDOH. If members have food insecurity, risk losing their homes, don’t have support systems or lack health literacy about their conditions, it’s hard to get them to focus on the steps to take for better physical and mental health. 

The most severe signs of disengagement include:

Medication non-adherence

This is especially concerning for members with chronic conditions such as diabetes, heart disease or respiratory issues. According to a study, 40-50 percent of patients prescribed medications to treat these chronic diseases don’t adhere. That can be because of costs, access or simply a refusal to take their medication. As a result, about 100,000 preventable deaths and $100 billion in unnecessary medical costs occur annually. 

Failure to see providers regularly or receive screenings

Another indicator of disengagement is when members stop seeing their providers or don’t have regular preventative procedures, such as mammograms or colonoscopies. When they aren’t under the care of clinicians, members have no attachment to their health. 

When they become ill due to a new or existing issue, they end up in the emergency room. Although they get immediate care, they aren’t seeing a provider that knows their history or specializes in their ailments. They are also left to their own devices for follow-up treatment, even if admitted to the facility. All of this significantly increases the cost of care. 

Seeking medical help isn’t convenient 

For any person on Medicare or Medicaid, getting to a provider can be a challenge. Barriers to access include a lack of transportation, lack of childcare and the inability to miss work. If your members don’t have the resources to seek care, they will stay disengaged and never make their health a priority.

Fear or mistrust of the health care system

Disengagement can be rooted in fear and mistrust. Depending on a member’s SDOH, history and other factors, they may be too scared to seek medical help, even when they know they need it. That same mistrust usually transfers to plans. It’s rather difficult to engage a member if they are skeptical of the entire health care system. 

Those feelings have only increased during the pandemic due to rampant misinformation. Often, vulnerable populations like Medicaid and Medicare members are more susceptible to false info. Different ethnicities are also more at risk due to America’s long history of mistreatment. A study of Black Americans that looked at their mistrust around COVID-19 found that 97 percent of participants “endorsed at least one general COVID-19 mistrust belief.”

A study of the general public, which included Asian, Black, Hispanic and white individuals of all demographics, revealed some more insights about mistrust:

• Older, more affluent individuals have higher levels of trust in physicians, but Black and Hispanic patients report much lower levels of trust.
• People do trust doctors (84 percent) more than the health care system (64 percent) and much more than government agencies (56 percent).
• Non-adherence to doctor orders (e.g., filled prescriptions, treatment recommendations, scheduling follow-ups, lifestyle changes) is greater in young adults, Black and Hispanic populations, those without college degrees and low-income households.

These results demonstrate the hurdle of trust for Medicare and Medicaid plans. The research makes strong conclusions that those least likely to engage with the health care system and adhere to treatment have the same demographics as many Medicaid members. 

However, plans may not know the best way to address these causes of disengagement. They realize the value of engagement and often have many programs in place, but they don't always hit the mark. If plans strive toward this goal without an effective strategy, they are bound to hit roadblocks. 

Plans have long been aspirational in their pursuit of greater member engagement. They’ve deployed strategies and adopted technology, proactive outreach, and internal processes that they believe will drive higher engagement. 

Unfortunately, much of this effort has not provided the expected results. So why are plans falling short?

1. Engagement metrics
2. Unique populations
3. Communication
4. Data use
5. Loneliness connection

1. Engagement metrics

Measuring the right things

As noted, engagement is measurable. However, one of the primary issues that plans face in cultivating greater member engagement is measuring the wrong things. A lengthy list of metrics that seem like they would indicate better engagement actually don’t. To determine if your metrics tell the whole story, take a closer look. How did you decide to measure these metrics? Why did you consider them to be indicators of engagement? Most plans don’t know how to do this or lack the structure to measure it. If you’re in this category, you’re likely tracking these standard measures:

MA Star Ratings are critical to your plan, and you will attract more members with higher ratings. They quantify satisfaction, but that’s not always the same as engagement.

Healthcare Effectiveness Data and Information Set (HEDIS) performance data does show plans how they can improve quality. It also looks at access and experience, but it may not answer the engagement question.

General surveys to members are something to continue using, but you may want to look at what you’re asking. Do the questions focus on whether your plan meets minimal criteria? If so, you’re not going to learn about engagement.

2. Unique populations

Develop specific engagement strategies for high-utilizers

You have a diverse group of members, but when it comes to making strides on engagement, targeting high-cost members should be a priority and have its own strategy. High-utilizers often have chronic conditions, non-compliant health plans or care gaps.

The more you can segment members by their diagnosis, SDOH, care needs and levels of engagement, the more impact you can have. If you narrow your strategy to those that would benefit the most, you will experience higher engagement. In turn, you can improve your members’ compliance and make them more involved in their health with a more targeted, tailored approach.

3. Communication

Personalize communication to build trust

You will build trust if you consistently deliver valuable communications with empathy and compassion, and we all know that trust is key to engagement. Continue to provide members with accurate information and mitigate falsehoods, and they are more likely to listen. The second part of communication is how you do it. The modern world offers many options. Think back to the MA satisfaction study and the increase in member portal adoption. Technology can be a crucial component of your communication strategy. Medicaid plans can also use tech, as the proliferation of smartphones is almost universal, even in lower-income households. You can also ask about communication preferences. Do they want communications via mail, phone calls, emails, texts or something else? Some may prefer many different lines of communication, so it’s important to be omnichannel and relay information in the most convenient format for your members.

4. Data use 

Focus on health care activities that correlate to engagement

Are your focus areas not contributing to engagement? Sometimes, it’s easy to overlook engagement. You’re busy with the basics, trying to reduce costs and support higher quality care. To understand connections, you need to look at your data and determine which activities correlate to improved health outcomes. You have a wealth of data about your members and their health history. Analyzing it through artificial intelligence (AI) delivers crucial insights. Based on your findings, you can personalize activities based on the existing care gaps for high-risk members. For example, there are often incentives for annual wellness visits. Still, some members would be better encouraged to see clinicians for specific tests or exams based on their chronic diseases, risks or age (e.g., mammograms, colonoscopy, cancer screenings). You can build trust by prioritizing health activities that are more likely to keep members healthy.

You should also start thinking outside of physical health activities. Often the most impactful activities that lead to engagement concern mental health. One of the most complex and instrumental activities to improve engagement is managing loneliness. The science of loneliness has just recently become mainstream. It’s not a feeling; it’s a complex condition and a stumbling block to engagement.

5. Loneliness connection

Address loneliness to break through to members

Does your plan currently consider loneliness a condition? Have you ever attempted to intervene with members based on loneliness? If not, then this is entirely new territory, but it could be the most impactful change you make regarding engagement. The science of loneliness is based on considerable research. Loneliness has been linked to greater use of opioids, NSAIDs and sleep medications. It contributes to morbidity and mortality, impacts mental and physical health, and can occur across every gender and age group. Loneliness isn’t solely about isolation; it’s more complex than that, and it weighs on the hearts and minds of many of your members.

By correcting the issues that could be hindering engagement, your plan can take control of this issue. Addressing loneliness deserves to be at the top of that list. By creating strategies to treat loneliness, your members can get healthier, and so can your bottom line.

The Pyx Health platform gathers data to understand the mental and physical well-being of the member and SDOH needs. These findings inform our interactions, ensuring they are compassionate and respectful. This process treats members as humans, not as numbers, supporting trust-building.

From there, the connections begin. Members can interact with our chatbot “Pyxir” and our team of ANDYs™ (Authentic, Nurturing, Dependable, Your Friends). Members gain connections with people who listen to them, with no limitation on time. Pyxir and the ANDYs can guide members to appropriate care and remind them of plan benefits. Such experiences drive engagement and deliver better outcomes. Programs are available for both Medicare and Medicaid.