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At the end of the year, do you assess member benefit engagement? If so, do you do any outreach?
Denise: Yes, we look to see if members have gone in for their annual wellness visits and will check to see if there are any gaps in care such as breast cancer or colorectal screenings. It’s a multimodal outreach campaign at this point to encourage their engagement. We engage our broker and provider partners and then we will text, email, mail, and call members to promote overall a healthy living that leads to the care they need.
Are there any trends that you are observing in terms of open enrollment this year (2023)?
Denise: Open enrollment trends really do depend on the market. For me, in the northeast, we work a lot with broker partners and we are seeing that channel perform exceptionally well. Broker partners play a vital role during AEP as they are the trusted voices among communities. They offer members expert guidance and ongoing assistance. With the ever-present evolution of health plans in various markets, I really anticipate that these partners are going to play an increasingly significant role in future AEP’s. This type of partnership can be somewhat new but I think we need to keep evolving in these relationships to see the best overall success. Additionally, we’re seeing for the first time since COVID-19 that people are getting back to face-to face meetings, pen and paper – tangible elections. With this, it’s pertinent to meet members where they are. Offering a variety of avenues for members to elect coverage communicates intentionality that will set you apart. Whether that’s electronic, mail-in options, or in-person meetings, as health plans, we need to adapt to our members’ needs and speak to them the way they want to be spoken to.
How do you ensure continuity of care for new members currently using DME? Are there processes or messages that are especially helpful for helping members navigate potential changes? Are they different for current vs. new members? Are there pitfalls that should be avoided?
Denise: Naturally, there are some inevitable complications that come along with open enrollment and so there will be some members that have more challenging plans to navigate depending on their situation. I’ve seen someone trying to join our plan with an oxygen need, and part of their process was having to figure out if their current DME provider would be covered under the new plan and if they were going to have to go to their physician again for another prescription order. All of these considerations can be stressful for members. As a health plan, I believe this is where proactive identification is key and provides a solution to meet people where they are. At Point32, shortly after onboarding new members, we deploy welcome calls to a subset of our members. Our goal is to gather information on this call that could pose a challenge for the member. Also, we deploy health risk assessments to our entire population because we want to identify members’ needs, including those with DME needs, and use that information to avoid any continuity of care challenges. As a health plan, providing a positive experience for members is one thing but ensuring there are no gaps in care is just as important! Many people have come to believe that health plans are like the “Big Bad Wolf” that isn’t there to help at all – we as health plans need to work to eradicate this perception and help people to understand that we want them to be healthy and that we are in their corner.
What are the best practices in terms of informing current and future members about how their enrollment will impact cost sharing, prior authorization, and other processes used for services they are currently using?
In terms of informing current or potential members about enrollment plan shifts, health plans need to be honed into communicating the benefit information via various channels. Timely notifications, educational meetings highlighting specific changes in cost sharing and processes, and visual aids – these are all options to consider communicating benefit changes. Additionally, health plans should collaborate with healthcare providers and communicate any and all changes to plans. Once collaboration is established, it’s best practice to put a feedback system in place so that you can track progress and shared information. At Point32, our Population Health team really helps engage and communicate with members regarding any changes to their current plans so that they can make the best choice during an upcoming enrollment. This is a year round commitment we make to our members. Strategies like these will ensure that members understand the impact on their services and hopefully reduce confusion and promote a positive enrollment experience.
“We as health plans have a lot of information that can help us look for members that need assistance. It behooves us to be intentional about member engagement and outreach. Look at the data you have regarding your offerings and engage your members based on the facts. At the end of the day - help build plans that result in more positive health outcomes for your members.”
Michael Cantor, M.D.
Dr. Mike Cantor is a geriatrician and attorney who has extensive experience designing and implementing value-based care, quality improvement, and care management programs for healthcare providers and health plans. He works as a fractional (part-time) Chief Medical Advisor for Aeroflow Healthcare, Uber Health, and other technology-enabled health services companies, value-based care organizations and digital health companies. Previous roles include: CMO for Bright Health Plan, an innovative health
insurer; CMO for CareCentrix, a leading outsourced home health, durable medical equipment, and post- acute care benefits manager recently acquired by Walgreens; and CMO for the New England Quality Care Alliance (NEQCA), the physician network affiliated with Tufts Medical Center, where he implemented network-wide quality improvement and care management programs for 150,000 managed care lives. He trained in internal medicine at Beth Israel Hospital in Boston and did his geriatrics fellowship at Harvard Medical School. He has degrees in law and medicine from the University of Illinois.
Denise Doucette-Ginise, MSN, RN, CCM, CHPN
Denise is an accomplished nurse executive with a unique background combining clinical expertise, entrepreneurial leadership, and a breadth of experience across the healthcare industry.She currently serves as the Director of Medicare Member Experience for Point32Health, the parent organization of New England’s iconic managed care organizations, Tufts Health Plan and Harvard Pilgrim Healthcare. Tufts Medicare Preferred is one of very few HMO plans in the country to achieve 5-STAR from the Center for Medicare & Medicaid Services for eight years.
