Healthcare Open Enrollment Means Marketers Ask: Whose Patient Are You, Really?

It’s Open Enrollment season in health care. Marketers at physician groups, hospitals, and health plans compete for attention and selection. These high-profile marketing campaigns tend to overshadow a new wrinkle that adds complexity behind the scenes — patient attribution.

It’s Open Enrollment season in health care. Marketers at physician groups, hospitals, and health plans compete for attention and selection because the choices made now will drive patient traffic and revenue potential over the coming year. These high-profile marketing campaigns tend to overshadow a new wrinkle that adds complexity behind the scenes — patient attribution.

Patient attribution is rising in importance as part of the overall shift toward Accountable Care Organizations (ACOs), value-based care, population health, and social determinents of health. All of these trends require a provider or provider’s organization to be more engaged, proactive, and mindful of resource utilization. In an HMO model, the responsiblity rests with the assigned or chosen primary care physician (PCP), known as a “patient choice” attribution method. The PCP does an initial evaluation and determines when more specialized care is appropriate. But this obvious direct accountability is not present in other types of coverage, where the healthplan design does not require the patient to choose a PCP. In these situations, patients can bounce from physician-to-physician and hospital-to-hospital, with only the insurance company having an understanding of the patient’s health situation — based on the claims they pay.

This is where patient attribution comes into play. The idea is that clear lines of responsibility lead to more efficient use of resources and earlier resolution of health problems. But for a health plan to create accountability, it has to determine which provider or provider organization should benefit from the financial upside of success, or bear the downside risk for poorly managing a patient’s care. Providers and provider organizations with attributed patients can realize significant performance-based bonuses, if the oversight efforts result in more efficient use of resources, better clinical documentation, or improvements in their overall panel’s health. The downside is that a physician can be assigned — and remains responsible for — attributed patients who never come into the practice, which occurs most often if the provider does not have a strong outreach program.

Attributing a patient is not a simple matter. Each has strengths and different implications for the type of marketing service you might offer a provider or organization. If your hospital or physician group holds multiple value-based contracts, focus your marketing efforts on the agreements that offer the most financial “upside,” based on the number of lives under that health plan contract or based on whether the clinical performance targets outlined in the agreement are achieveable.

While there are several attribution models, the most common are Prospective Attribution, Retrospective Attribution, and Geography-Based Attribution. As a marketer, the outreach strategies and tactics you recommend may differ, depending on the the attribution method.

The retrospective approach relies on the patient’s visit history (sometimes called visit-based attribution). The patient is attributed to the physician or provider organization the patient went to most frequently. In some cases, that attribution may be to a specialist, rather than a PCP. This rear-view mirror approach has the advantage of retrospective accuracy, but also the weakness of assuming the patients’ behavior in the coming year can be based on their behavior in the prior year. As a marketer, your goal is to solidfy a relationship such that the patient would be strongly predisposed to returning.

In a prospective attribution model, the health plan will assign the patient to a provider or provider organization, with the expectation the provider will reach out to the patient to create initial and ongoing engagement. While the provider has clarity about who they are responsible for, patients may not respond to that outreach. As a marketer, your opportunity is to make getting the first appointment easy and the experience pleasant, so they do not feel a need to go elsewhere.

A geography-based attribution is an approach that assigns patients to nearby providers, often at the ZIP code level. The proximity of the provider’s office to the patient’s residence can be attractive to many consumers, increasing the odds the patient will remain with that practice. The weakness in this model is that it does not take into account the actual health needs of the patient who may need to see a specialist more frequently than a PCP. Geography-based marketing is a natural fit for most marketers, both in the real world or digital world.

As you execute upon this year’s open enrollment outreach, open a discussion with your contracting team about value-based agreements and the attribution models used. It may help frame some of the activities you pursue after the new year.

‘Tis the Season … for Term Letters in Healthcare

Nothing says “happy holidays” like a year-end coverage termination notice. It’s particularly awkward this time of year, because it overlaps open enrollment for commercial, Medicare Advantage and Exchange members. In this column, we’ll look at five seasonal drivers within healthcare, and how marketers can prepare for term letters, open enrollment and more.

Nothing says “happy holidays” like a year-end termination notice. It’s not unusual for healthcare organizations engaged in contract negotiations to send term letters to patients in mid-November. The notices fulfill contractual and regulatory obligations to provide advance notice to patients while also ratcheting up the pressure to reach agreement before a January 1 effective date.

This would cause headaches for marketing and communication professionals under the best of circumstances, but it’s particularly awkward this time of year because it overlaps open enrollment for commercial, Medicare Advantage and Exchange members. This is just one of the external factors that creates seasonality in healthcare communications.

In this column, we’ll look at five seasonal drivers within healthcare and how marketers can prepare.

1. Termination Letters

Term letters are usually sent 45 days in advance of a contract’s renewal or end-date. While these can occur at any time, a common scenario is a termination letter sent by a health plan about six weeks before the end of a calendar year. The letter goes to patients of physicians/medical groups or hospitals covered under the contract in question.

In some cases, you may not know the term letters have gone out until you begin to receive frantic calls from patients wondering if scheduled appointments or procedures will be covered. This puts you in a terribly reactive situation.

Proactively, marketers should schedule quarterly meetings with their organization’s contracting department to discuss commercial, exchange and governmental agreements that are coming up for renewal. Your contracting team is likely to focus on the financial framework of the agreement, while your concern should be on how to manage the fear and uncertainty a potential disruption has on individual patients.

Coordination with your customer service team, as well as impacted physician practices, are also critical because they will be on the front line of inquiries. You will need to understand your state’s Continuity of Care guidelines, the terminating plan’s grace period (if any), and work cross functionally to help guide patients to in-network facilities or providers if the agreement ends.

This is a labor-intensive, detail-oriented process because of the number of potentially impacted people, and emotionally draining for the patient’s family. Communicate your awareness of the situation, provide updates often and be prepared for significant push-back and one-on-one problem solving.

2. Open Enrollment

Although open enrollment for major employers, general business, Medicare/Medicare Advantage and Exchange business differ, the main season occurs in the fall and early winter. Some organizations invest all their awareness efforts during this time, when in fact this is when you should be converting prospects based on the awareness, goodwill and brand desirability you’ve cultivated all year long.

The foundation for a successful open enrollment season is based, in part, on decisions made by upstream parties during the spring and summer. As 2018 approaches, be sure to build in strategies to reach large employers, brokers, physicians and health plans.