Health Plan Payment and Reimbursement

2 approaches illustrate best practices in digital patient engagement

September 26, 2019 1:39 pm
  • Digital patient engagement requires connecting with enrollees before they need care.
  • Digital price transparency tools are more used when they are very specific.
  • Provider use of digital tools offered by health plans requires minimizing time burdens.

Two insurers have identified separate approaches to digitally connecting with enrollees, who are typically resistant to engaging with such tools.

UPMC Health Plan, headquartered in Pittsburgh, has found that its enrollees’ use of cost transparency data to shop for providers is closely linked to the extent to which they know in advance that such data is available.

“At the time of an appointment is too late to provide cost numbers,” Elizabeth Riordan, a vice president for the health plan, said at an America’s Health Insurance Plans conference in Washington, D.C.

Such data also can put too much of a burden on enrollees to find the best deal. Generally, the health plan has found use of cost and quality data is concentrated in its younger, pre-Medicare plan populations.

Different types of tools will be needed to garner use among seniors, Riordan said.

Sophia Chang, MD, MPH, chief clinical informatics officer for Clover Health, a Medicare Advantage (MA) health plan based in San Francisco, said most people “don’t know what a star means” in the star ratings created by the Centers for Medicare & Medicaid Services to indicate overall hospital quality.

Where success in reaching enrollees has been found

Clover Health found some success by focusing its transparency tools on specific needs, like calculating how far a Medicare beneficiary is from falling into the so-called donut hole, the segment of drug spending per year for which a senior bears a larger share of the costs.

That is part of Clover’s effort to highly personalize the cost and quality data provided to MA enrollees. For example, the tools don’t identify merely a local orthopedic surgeon for someone who needs knee replacement, but a knee replacement surgeon specifically.

“That’s increasingly the challenge that we all have, to try to make the information as specific and as relevant as possible,” Chang said.

Chang, who long worked on cost and quality transparency tools for the California Healthcare Foundation, found there that the public generally was not interested in such tools.

“We continually saw that individuals were not interested in this,” Chang said. “It’s almost too abstract.”

Clover Health has followed the behavioral change models of various tech giants to address its leading challenge: changing the behaviors of Medicare enrollees. Chang credited those approaches with garnering an unusually high 81% patient engagement rate at the point of care.

How to get providers to use digital tools

Another longstanding problem facing health plans is provider resistance to the time and resource utilization required by many digital tools. UPMC Health Plan has found that value-based payment incentives need to penetrate all the way down to the individual clinicians providing the care, or they are unlikely to take the additional steps required to excel under the model.

“We also realized that asking someone to bolt on telehealth coverage to an existing practice is lunacy,” Riordan said.

UPMC Health Plan has recruited practices that are interested in generating savings by using a “digital first” model that treats lower-acuity conditions through telehealth. However, those practices also need to be willing to see patients in person so that Medicare beneficiaries have continuity of care with a clinician.

“When you are dealing with small practices, they do not have the capital to provide a compliant telehealth-based platform,” Riordan said.

Clover Health also has found that providers can become frozen by “way too much information,” Chang said. The plan has developed ways to distill the range of beneficiary information it collects and to prioritize for the provider the important areas to cover in the patient’s next examination.

“Or, for the office staff, [showing them] this is the most important thing to do for this patient so that they don’t come into the office, or before they come into the office,” Chang said. 

The health plan also has begun to filter such clinician-support information through the patient’s stated goals and objectives in areas such as palliative care.

Providers will be better able to collect the data needed for the health plan to predict the patient’s upcoming health needs and help coordinate care if the burden on physicians is minimized. Clover Health has promised physicians that sign up to its network that such data entry will require no more than five minutes, which Chang acknowledged is still a large share of the standard 15-minute visit.

Other elements Clover Health uses to entice providers to engage with its digital approach include:

  • Paying provider bills within seven days
  • Supporting clinical workflows for smaller practices that lack clinical support staff
  • Customizing patient data to provide it at the right time and place  


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