Face-to-face outreach to Medicaid clients works best, but many states still rely on confusingand ineffectivewritten materials
Medicaid Restrictions
May 31, 1997
Some 40% of New York City Medicaid managed care participants said they didn’t know—and were never told—they were limited to using network providers, according to a report by the Community Service Society of New York. A mere 18% of respondents knew there were restrictions on emergency room use.
Several participants at the National Academy for State Health Policy Conference in Seattle last month cited such statistics in their critique of many written educational materials and other outreach techniques used in Medicaid programs around the country.
A panel of Medicaid recipients at the conference agreed that one-on-one, face-to-face communications work best, yet a survey by Consultant Mary Kenesson found that only 16 of 40 states with Medicaid managed care programs offer face-to-face enrollment counseling.
Sue Stableford, director of the Health Literacy Center at the University of New England, says written materials are often among the least effective elements in outreach campaigns because a large percentage of health insurance information is written at a 10th grade level or above. She noted that some 75% of welfare recipients read at only basic levels.
But Ms. Stableford warned against relying simply on readability formulas. Written materials also should be evaluated for other areas of reader friendliness, such as use of white space, easy-to-understand graphics, concept density of text and vividness of language, she says. Grids, which are widely used for comparing plan features, are poorly understood by readers with below-average reading skills, she says.
Using a wide variety of educational approaches increases the likelihood of getting the message across, says Lou Bodian of New Jersey Medicaid. New Jersey found that sending appointment letters to AFDC recipients scheduling a talk with enrollment counselors worked better than running health fairs in communities. The state also used focus groups of Medicaid recipients both to develop and evaluate its education and outreach programs.
Surprisingly, one of the worst-informed groups about Medicaid managed care in several states are the providers themselves, several conference participants said. One reason: Information mailers are often included with payments that are seen by clerical staff but not providers. Since Medicaid recipients may rely on providers for information about insurance, including fee-for-service providers who aren't part of Medicaid networks, they need to be better informed.
Specialized training
Pamela Morris, president and CEO of the Dayton Area Health Plan, a Medicaid-only managed care organization, was one of several managed care representatives who stressed the importance of managed care plans having staff with specialized training and skills to work with the Medicaid population.
The Dayton plan uses community nurses and outreach specialists in one-on-one educational visits at home with Medicaid recipients. Such visits work better than other outreach methods, Ms. Morris says, because they offer a chance for direct health education, establish trust and permit identification of health or social problems that could affect plan members. Ms. Morris urged plans to hire former Medicaid recipients as outreach specialists because "they have walked that walk" and have more credibility with enrollees.
DAHP's outreach specialists focus on such areas as welcome calls, prenatal visits and high-risk pregnancy screenings. They also target emergency room over-utilization and noncompliance with plan rules.
Incentives for beneficiaries
The Dayton plan also has found that incentives can work in getting recipients to make better use of preventive care, managed care officials said. For instance, the Dayton Area Health Plan in Ohio uses gift certificates of up to $100 for mothers who keep their prenatal appointments and the six-week checkup for themselves and their babies. The certificate increases to $150 if the babies receive all indicated immunizations during the first six months.
Such incentives are part of extensive outreach efforts targeted to pregnant women, which have helped the plan rank below the state average in low birth rates in the Medicaid population, says Ms. Morris.
Prenatal outreach is essential for Medicaid managed care plans, since 50%t of Medicaid hospital admissions are maternity related, Ms. Morris says. But the Dayton plan's outreach services also target other hard-to-reach populations, such as the homeless, foster care children, children with asthma and the hearing-impaired.
Blue Cross and Blue Shield of Connecticut uses such factors as demographics and past utilization patterns to identify high-risk Medicaid enrollees to target for outreach, says Donna Moore, director of Government Managed Care. Among members automatically targeted for one-on-one outreach are those who are auto-assigned either to the plan or a primary care provider because they failed to make a choice. The plan has created a subsidiary with 21 employees, including 16 "access coordinators," to target high-risk members for one-on-one counseling.
Nurse hotline is important tool
Even if a Medicaid managed care plan doesn't have dedicated member service representatives or a well-staffed outreach program for Medicaid recipients, having a nurse hotline to field health questions and questions about plans.
Medicaid members are twice as likely as commercial members to call the NurseLine of Edina, Minn.-based United Healthcare, which operates Medicaid managed care plans in 11 states, says Catherine Halverson, vice president of Medicaid programs for the organization. United Healthcare gets 30 calls to its NurseLine per 1,000 members per year in its Medicaid plans. Ms. Halverson says the NurseLine has proven more effective in reaching Medicaid members than handbooks or newsletters.
Both states and health plans should strongly consider using local numbers, says Jane Perkins, staff attorney at the National Health Law Program, who said Medicaid recipients tend to place more trust in local numbers than toll-free 800 lines.
Community organizations can play a vital role in an effective outreach effort to Medicaid recipients.
One of the worst-informed groups about Medicaid managed care in several states are the providers themselves.
New Jersey Care 2000 required enrollment brokers to subcontract with community-based organization for advice on how to reach various communities, Mr. Bodian told the meeting of the National Academy for State Health Policy. The state also invited community based organization representatives to the initial bidders' conference to network with enrollment brokers.
Several conference participants suggested that state agencies and managed care plans seek input during regularly scheduled meetings of community organizations rather than attempt to set up their own meetings to discuss managed care issues on Medicaid.
—Jack Neff
Contact Mr. Bodian at 609)-588-2811; Ms. Burnell at 614-466-4693; Ms. Kenesson at 540-882-4431; Ms. Morris at 937-224-3300; and Ms. Stableford at 207-283-0171.
Face-to-face outreach to Medicaid clients works best, but many states still rely on confusingand ineffectivewritten materials
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