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Using Member Advocacy to Plug Costly Leakage in Medicare Advantage Networks


In a market where quality measures and patient satisfaction are critical, many Medicare Advantage plans form highly refined networks. After all, a smaller network of providers is both easier to manage and easier to influence to improve the overall member care experience. And better member experience can support improved Medicare Advantage CMS Star ratings, which in turn impact revenue and payment and enrollment patterns.

Often designed to leverage a health plan’s existing relationships with health systems or provider groups in targeted regions, narrower networks can also reduce unnecessary and avoidable utilization. They do this by helping members get the care they need in the most streamlined and convenient way, at the lowest cost.

While these cultivated networks can be attractive to members because they offer a lower premium versus wider networks, they can also result in challenges for consumers and for plans—like out-of-network leakage. That’s not surprising, since a report from the Urban Institute found that narrow care networks often include less than one-third of the eligible clinicians in an area.

Network leakage and fragmented patient care

One important issue with network leakage is that it can negatively impact the very thing narrow networks hope to support—quality of care. Medical reports, imaging and lab results, and other important patient history information are often not as easily accessible to out-of-network specialists. Plus, the relay of this information can take longer because processes may not be in place to quickly transfer these records out-of-network.

Another challenge: Decisions made during an out-of-network physician visit aren’t always captured in the in-network electronic health record (EHR) software. This skews the health system’s clinical alignment and makes it difficult for in-network physicians to have access to the latest information necessary to coordinate patient care.

The resulting fragmentation between the in-network physician and out-of-network providers (and the health plan) can result in miscommunication, delays in diagnosis or care, duplication of services and denied referrals. In some cases, this fragmentation has even led to malpractice claims.

Networks leaks are costly, too

So what does network leakage translate into for healthcare organizations? A survey of healthcare executives found:

  • Four out of 10 reported they lose at least 10% of annual revenue due to network leakage; one in five said they lose up to 20%.
  • One in five of the execs also don’t understand exactly where the leakage is occurring or why it happens.
  • Another interesting point: Almost one in four organizations do not track or quantify patient leakage.

Out-of-network care decisions can negate potential Stars increases and ultimately lead to a consumer’s decision to change insurance plans.

Finding—and addressing—the leakage points with health advocacy

Most healthcare organizations face four primary leakage points: member/patient awareness, physician referrals, care coordination and ease of use of in-network providers.

The good news is that each of these network leakage points can be addressed by heightened member services or health advocacy (also called healthcare navigation or health plan concierge-level service).

Let’s break it down:

Lack of awareness: Just as plans and health systems are sometimes not aware of leakage, members and patients are often not aware of their options and how much the different options may cost them. Health advocates can proactively provide upfront education and information, and guide members through the process of either staying in network or finding their lowest cost option and easier coordination out of network. This can be done at several points in the member-plan relationship: during member onboarding, when provider data indicates a referral is being issued, or after an out-of-network claim is processed to prevent additional leakage.

This type of approach pays off. Carenet helped one plan save nearly $1,000 per patient by steering screenings to high-quality, low-cost diagnostic imaging facilities that were in-network.

Physician referrals: Health plans are increasingly leveraging their utilization management expertise to help in-network provider groups and health systems understand leakage and referral patterns and their cost drivers. Healthcare advocates focused on provider-plan relations can take this one step further by providing insights into longitudinal care across systems.

Additionally, providers and plans can work together to create data-driven, triggered outreach when a flag indicates a member has been referred for out-of-network services.

Care coordination: Here’s where health advocacy can really shine, taking on the often-complex array of tasks that are needed for seamless member care coordination. Advocates can help members with the all-important in-network provider selection, research different providers’ appointment availability and quality measures scores, help with medical record transfers, assist with lab/imaging and specialist appointment scheduling and more.

Healthcare navigation specialists are also typically trained to communicate with members who have fragmented care teams to resolve issues. They can especially help those who have not identified a primary care physician—solving for potential leakage before it happens.

One study found that decreasing the percentage of primary care delivered out-of-network, across all Medicare accountable care organizations, by just one-tenth of a percentage point could save the Medicare system $45 million annually.

Ease of use: With a concierge-level advocate as a resource for members, using in-network providers is made easier. Advocates can be a guide to finding the right providers and facilities with just one portal chat, text or phone call. And again, advocates can serve as a conduit between in-network providers and the health plan to ease any points of potential friction in terms of ease of use.

This can be particularly important for members who may also need social determinants of health addressed. In fact, leakage tends to be higher in marginalized communities and among minority patients. This may be due to the fact that those populations have a more difficult time maintaining continuity of care and experience more barriers to seeing the same primary care provider repeatedly.

Health advocates can also be a key part of a leakage prevention program that identifies members with at-risk member experience scores and proactively engages them to improve their ease-of-use satisfaction by listening and problem-solving.

Post content provided by the Office of the Chief Growth and Strategy Officer at Carenet Health.

Learn more

If you’d like to talk more about advocacy and navigation programs and how they can address network leakage and improve Star ratings, contact us today. We’re happy to schedule a conversation and share our insights from working with more than 100 of the nation’s most consumer-centric health plans.


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