Know. Manage. Engage. Three Tools for Positive Healthcare Management.

We can hardly go a day, let alone several times a day without hearing various pundits comment on what to do with our nation’s healthcare issue. This is not a partisan issue, nor is it a fully a political issue.

As Americans, we know healthcare is a huge percentage of our economy. Frankly, no silver bullet exists to magically fix it overnight. We have had industry regulations, good attempts at interoperability, empowerment, risk-sharing and pricing, innovation, and many other inventions to get at the heart of the issue. Optimistically, you can see at least the trend slowing slightly, but one could argue much of that is the result of passing along the expense to the consumer.

A few challenges beginning to see resolution in the marketplace through early intervention are knowing, managing, and engaging members. Members needs to feel supported, engaged, and able to take actions as they are ready. This is especially important for the most vulnerable individuals who may have tough co-morbidities or compounding behavioral health issues. These higher-risk populations could benefit most from essential care coordination and intervention.

  • Know Your Member Day 1: Member Risk Stratification. Leverage shared data including past historical claims, encounter, social, clinical, and any other supporting sources to help profile a member’s potential risk on day 1. This allows more immediacy in how to interact with your new member. This replaces the cumbersome process of developing a member profile after six months of claims experience and conversations. (And then the member switches plans again at 12 months.) This churn in healthcare is not member-centric, and we can change that.
  • Manage Your Member Day 2: Member Care Coordination. Integrated care programs – whether you are a provider taking risk, or if you are a health plan or an Accountable Care Organization – your specific engagement model is what makes you special. The key to helping the system as a whole is how the care plans and program model are shared with future care plans. So, at the heart of the model is that member centricity, instead of a hardened model where plans and communications don’t carry forward with the member. Let’s advance our thinking to ensure all vendors help focus our solutions on the member. This carries progress forward and can help bend the cost curve by removing costly duplicative waste.
  • Engage With Your Member Day 3: Targeted Member Outreach. Leverage historical, behavioral, and social analytics to understand when, where, and how a member wants and is open to receiving communication. There are far too many outreaches that don’t achieve targeted results. (How many of you threw away the postcard from your plan on some reminder you were too busy to act upon?) We all grow frustrated with communications and waste, and each of us has a personal way we listen or can take action. Let’s create member-centric and personally targeted communications to achieve the desired result for both parties.

What if we add Knowing Your Member + Managing Your Member + Engaging Your Member and we optimized that to help bend the cost curve and raise member satisfaction? That’s a win. There is a ton of innovation happening in healthcare – and that innovation will have to disrupt how we do things today. If we are open to change, we can help improve the system as a whole.


Cynthia Nustad is Executive Vice President and Chief Strategy Officer for HMS.