Introduction:
During the 2020 open enrollment session, 1.2 million out of the 11.3 million Medicare Advantage enrollees in 2019 voluntarily switched plans. Maintaining enrollment is essential for consistent revenue, with payments based on member premiums and government funding. Risk adjustment vendors and robust risk adjustment coding are vital to ensure equitable care by providing additional funds for members with specific medical conditions. Nevertheless, retaining members and minimizing disenrollment’s are crucial to protecting yearly income, as acquiring new members can be costly—ranging from over $100 for private insurance members to over $700 for Medicare Advantage members.
Importance of Member Retention in Medicare Advantage Plans
Membership Dynamics Influence Star Rating
In some markets, member retention is closely tied to bonus payments and quality scores. The Medicare Advantage Star Ratings heavily consider the enrollment measure, which assesses the proportion of members opting out of a plan, significantly influencing the overall rating. Achieving four or more stars requires prioritizing both member experience and loyalty.
While Medicaid quality metrics don’t directly factor in enrollment, membership is crucial for calculating quality incentives in pay-for-performance and withhold programs. Retention plays a key role in driving quality outcomes and financial rewards across different healthcare models. To be eligible for a Star Rating under the Health Insurance Marketplace® Quality Ratings System, ACA plans must maintain an enrollment of at least 500 members within a contract period from July 1 to January 1. Additionally, the evaluation of quality incentives, healthcare utilization, and market expansion should be conducted alongside member retention rates, which play a pivotal role in determining the financial success of health plans.
Never Miss an Opportunity to Retain Members
Over time, the more opportunities arise to enhance health outcomes and improve quality scores as a member remains with a health plan. It is imperative that plans leverage these opportunities by enhancing member engagement in their healthcare, from the initial enrollment process to the subsequent re-enrollment.
The initial months following enrollment are crucial for enabling members to start their health journeys by selecting primary care providers, receiving preventive care, and identifying chronic conditions or risk factors. Plans that engage members earlier in the year are more likely to foster loyalty and improve health outcomes. By maintaining these efforts throughout the year, plans can achieve improved health outcomes, higher quality scores, and stronger retention rates.
However, these improvements can be jeopardized by interruptions in care, such as voluntary disenrollment or loss of coverage. A lack of consistent coverage can lead to delays in treating serious conditions like stroke or Alzheimer’s, missed preventive visits, and a rise in healthcare expenses. Continuous coverage is especially important for members with chronic conditions such as diabetes or hypertension. Coverage gaps make it challenging for members to maintain treatment or adhere to medication, resulting in increased emergency room utilization rates. Health plans play a crucial role in enabling these members to manage their health by providing appropriate engagement, education, and resources.
Leveraging Technology to Enhance Member Engagement and Efficiency
As each Medicare Advantage marketing season becomes increasingly competitive, leveraging technology and automation tools is essential for driving performance. Today’s Medicare beneficiaries are more tech-savvy than ever, expecting personalized, timely communications delivered through their preferred channels. Without the ability to automate outreach sequences using advanced contact center software, teams risk missing valuable enrollment opportunities.
Furthermore, Medicare marketing and sales strategies must be data-driven. Whether selecting which leads to contact or prioritizing enrollees for retention efforts, comprehensive and detailed reporting tools are crucial.
How Tech Enables Health Plans to Retain Members
How can you ensure that your team efficiently and effectively reaches leads and enrollees during enrollment season and beyond? The solution lies in implementing a robust dialer system at the core of your marketing and sales strategy—one that integrates data-driven insights with winning tactics to ensure success. Healthcare providers within Medicare Advantage are increasingly integrating AI into various aspects of their operations. For instance, RAAPID’s Neuro-Symbolic AI is being used to enhance risk adjustment outcomes that act as guardrails to equitable healthcare and give health plans a competitive advantage.
Currently, the healthcare sector, including health plans, has been employing AI in a piecemeal fashion, focusing on smaller pilot projects to boost efficiency and familiarity with the technology. Therefore, a unified strategy combining generative AI, Machine Learning (ML), and smart analytics into cohesive risk adjustment and healthcare solutions is needed to gain a competitive edge in Medicare Advantage product design and keep enrollments steady and increasing.
Enhancing Patient Engagement and Satisfaction
By embracing a robust digital health strategy, Medicare Advantage payers can improve their capacity to attract, engage, and retain members, thereby positioning themselves to capitalize on potential growth opportunities in the future. Creating a more user-friendly website is a highly effective and industry-recognized strategy for boosting user acquisition. This goes beyond just improving accessibility; it’s about making the site more consumer-oriented. As selecting a healthcare plan differs from shopping for clothing or electronics, healthcare organizations can still adopt valuable lessons from eCommerce sites in terms of website usability.
Consider these suggestions to get started:
- Simple comparison charts that clearly display the features, benefits, star ratings, and costs of various plans, allowing for side-by-side evaluation.
- Interactive quizzes that guide visitors toward the most suitable plan for their needs.
- Chatbots that address frequently asked questions (FAQs) and direct users to relevant information.
- Engaging, interactive content like videos and infographics.
- Accessible design elements such as closed captions on videos, alt text for images, and keyboard navigation for screen reader users.
Digital is the New Normal – Service Member Response Using Online Channels
Confusing payment processes often frustrate members, but simplifying them with digital options, cost breakdowns, and payment plans can alleviate stress. AI-powered customer service chatbots can efficiently handle common queries, reducing the load on support teams, though complex issues still require human assistance.
To retain Medicare Advantage members, health plans should listen and act on feedback through digital surveys, as traditional methods are slow and ineffective. Online text surveys allow faster responses, improving satisfaction. Many Medicare Advantage carriers have AI and data analytics, but proper integration into workflows is essential for adoption.
The Role of Risk Adjustment Vendors in Technology Integration
Healthcare organizations need to adapt to new workflows in the post-pandemic era. Vendors must be cautious not to overextend themselves to meet consumer demands as it may lead to a decline in performance. As key players in the healthcare industry, vendors have the responsibility to continuously improve patient care by integrating cutting-edge technologies and actively involving patients in their care journey. Vendors that integrate AI, natural language processing (NLP), and smart analytics with cloud-based solutions are highly sought after to improve the accuracy of HCC coding and bridge care gaps.
At RAAPID, we believe that although incorporating advanced technologies into existing systems can be challenging, users can still maximize their value and appreciate the impact of Knowledge Graphs and cNLP on clinical documentation and coding analysis.
Adaptive Capability: Vendor Solution Works Best with Localization and Customization
Vendors invest significant time understanding health plans’ native processes to ensure seamless integration of risk adjustment solutions with existing systems. This approach enhances health plans’ confidence in healthtech tools for managing comprehensive care. The adaptability of vendor solutions, especially through API integration, is highly valued, despite initial time requirements.
Secure integration of clinical data systems and EHRs as per HIPPA norms enables precise data capture for risk adjustment. Collaborative vendor practices, including user feedback & stakeholder education, foster strong relationships and validate their platforms for compliance and future needs. These innovations drive value-based payment models, automate clinical workflows, and enhance collaboration between payers, providers, and members.
Conclusion
Effective member retention is essential for maintaining financial stability and improving health outcomes across Medicare Advantage and other healthcare plans. Leveraging technology such as AI, automation, and personalized communication can significantly enhance member engagement, retention, and satisfaction. By fostering strong relationships and seamlessly integrating advanced vendor solutions, health plans can drive value-based care while securing a competitive edge in today’s dynamic healthcare market. Risk adjustment vendors and risk adjustment coding play critical roles in this process, ensuring that health plans can effectively manage risk and provide equitable care to their members. Prioritizing member loyalty and optimizing operational efficiency will continue to be key drivers of success.
