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Enrollee Advisory Committees for Dual – Special Needs Plans: A Challenge, and a Tremendous Opportunity to Improve Plan and Member Outcomes

The implementation of Enrollee Advisory Committees (EAC) are a new  regulatory requirement for Dual-Special Needs Plans (D-SNP) for 2023.  and constitute one of the most powerful opportunities for plans to gather the needed insights to improve member retention, market competitiveness, member experience and product design and power their plan’s growth.

Enterprises seeking growth and improved quality must flip challenges into opportunities. For providers of Dual-Special Needs Plans (D-SNPs), one such challenge is looming, arriving via a new Centers for Medicare & Medicaid Services (CMS) regulation that mandates providers include enrollees in plan governance beginning 2023. 

Specifically, providers will have to set up and maintain Enrollee Advisory Committees (EACs) for their D-SNP members for every state in which the plan operates. These are part of a broader initiative by the federal government toward meaningful healthcare consumer engagement at a local level. The goal of EACs is not just to set up a token board or a focus group, but to be part of truly shared governance.

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As daunting as it may seem, creating and maintaining these EACs offers an opportunity to consult with D-SNP members on critical member experience and plan issues, including improving health equity for its underserved populations to improve plan performance and also to grow a plan’s Medicare Advantage membership, a goal all providers of D-SNPs certainly share.

Warning: Bumps ahead

First, let’s explore the challenges.  

For the average D-SNP plan, setting up and maintaining EACs will require a $1 million annual investment, based on CMS estimates, along with about 3,500 hours to create and manage such an effort. 

Those costs in money and time will multiply exponentially for D-SNPs offering plans in more than one state. 

These burdens are occurring as the environment for D-SNPs become increasingly competitive with plans racing to win a larger share of the estimated 12 million dually eligible (for both Medicare and Medicaid benefits) beneficiaries. Plans compete aggressively to acquire and retain members differentiating on their offerings, their experiences and cost.  However, competition has reduced cost burdens, with about 60 percent of Medicare Advantage members and nearly all D-SNP members in zero-cost plans, requiring plans to find other ways to attract and retain members.

While the dual-eligible population is attractive to many plans, serving the population effectively is challenging for plans and their partners. Plans typically see low beneficiary engagement in plans, high beneficiary churn and retention challenges, and high costs associated with managing their care. Plans have also found it hard to get consistent and comprehensive information about the ongoing needs of the changing population.  EACs, if done right, can serve as a new channel for plans to receive rich and ongoing member input on critical plan issues with the goal to improve member experiences and plan outcomes. 

Meanwhile, although CMS has deferred to plans to work out the details for the committees, providers will still be held accountable for meeting certain criteria laid out by the agency.

For example, providers must ensure the EACs accurately reflect the diversity of a plan’s membership, including those from rural areas, members with disabilities, and a broad spectrum of minority groups. Achieving broad representation will be key, since improving equity is a central goal of the EAC initiative.

And while the CMS does not have requirements specifying meeting locations, or formats, it is encouraging providers of D-SNPs to adopt “identified best practices” to make sure meetings are well attended and accessible to all enrollees, including those with limited digital literacy or members lacking access to technology or broadband. And EACs will need to meet federal requirements related to accessibility for those with disabilities. 

After creating the diverse and representative committees, other critical tasks for providers of D-SNPs include preparing materials to educate committee members about issues; creating a plan for attendance management to avoid no-shows; and capturing data and creating audit-ready documentation. 

The Road to Opportunity

Beyond this to-do list, providers can focus on some big-picture items to ensure success in compliance and also flip the challenge into opportunity:  

1) Audit your attitude:
A provider can take a ‘check the compliance boxes’ attitude and stay out of regulatory trouble in the first year. But if poor member attendance at EAC meetings and poor documentation of meetings snowball, providers of D-SNPs could soon have a major compliance headache.

Instead, take a more comprehensive, positive approach to creating an EAC because of its inherent benefits: Optimized, the committees could help improve customer service, increase member retention, boost a plan’s Medicare Advantage Star rating (a measure of a plan’s quality), attract more members and help the plan capture greater market share.

For example, when it comes to improving customer service, enterprise leaders know that survey data isn’t sufficient – a business needs to get at the emotions driving consumer decisions. D-SNP providers, specifically, must learn about the “switch triggers” that may cause members to change plans. EACs can help, leading providers to identify new processes or benefits that might retain members.

Innovative plans are already seeing the opportunity to leverage the requirement and capture valuable member insights on their benefits offerings, local provider and hospital access and coordination challenges, and ways to address health equity.

2) Get help: To get through the challenge of setting up and managing EACs, providers will need partners to help create the EACs and support them through the implementation and maintenance phases. Those partners can help to identify, engage and reach diverse D-SNP members across a state, including the hard-to-reach populations such as the homeless and those will low health literacy or available health access. 

D-SNPs should seek partners capable of using advanced analytics and artificial intelligence to analyze data above and beyond Medicare, to learn more about their existing member needs and identify hidden barriers. Partners genuinely committed to health consumer education, effective member engagement, responsive customer service, and improving members’ health will generate the sort of membership retention and recruitment that will lead to steady long-term growth. 

3) Create continuous learning: Each meeting should be viewed as an opportunity to improve the next, from details such as membership attendance to the development of an agenda that produces meaningful outcomes. Data and insights generated from meetings should be stored securely and ready for audits by the CMS. Meanwhile, providers should use the membership feedback from EACs to develop enterprise strategy, including the creation of action plans for plan-wide change. 

Carpe Diem

A Plan whose top priority is to improve member experiences, quality and achieve plan outcomes, should view the EACs and CMS’s new requirement as a powerful tool for achieving these goals and driving membership growth in a complex patient population when plans work collaboratively with members and partners and embrace the challenge.

Dr. Shub Debgupta is founder and chief executive officer at Predict Health, a deep technology analytics company transforming how the nation’s 60 million seniors navigate and manage their health experience with Medicare and Medicaid.

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