Policy & Regulation News

Patient Engagement Requirements by Private, Public Payers

Medicare, Medicaid, and private health payers have different patient engagement requirements.

There are different patient engagement requirements based on private and public healthcare payers.

Source: Thinkstock

By Sara Heath

- Although patient-centered care relies on positive patient-provider relationships, various private payers and public insurers face differing patient engagement requirements.

Providers may see different incentive payments based upon a patient’s primary healthcare payer. MACRA and meaningful use, both pertaining to Medicare beneficiaries, have their own set of concrete requirements to which providers must adhere to receive a full incentive payment.

On the private side, payers use their own tactics to interact directly with consumers by offering cost transparency and more consumer choice. Private payers also leverage their own tactics to keep patients engaged in their own health management plans.

Below, discusses the differences in patient engagement based upon Medicare or Medicaid and private payers.

Healthcare access equal across payers

As of the time of publication, the ACA requires all healthcare payers – whether on the individual market, a part of an employer-sponsored package, Medicare, or Medicaid – to offer patients one free annual physical. Apart from that requirement, there very few specific or distinguishable regulations for healthcare access across any type of payer.

READ MORE: How Will MACRA Impact Patient Engagement, Care Coordination?

However, patient care access is still an important characteristic to understand between Medicare, Medicaid, and privately-held insurance. Despite instincts to the contrary, Medicaid patients experience equally available care access compared to privately-insured or Medicare patients.

While it could be presumed that Medicaid expansions and general rises in insured patients due to the ACA cause limited access to healthcare, two separate studies have indicated that Medicaid care access is on par with privately insured patients. Furthermore, these studies show Medicaid care access has risen in recent years.

A data brief published by the Kaiser Family Foundation showed that 70 percent of providers now accept Medicaid patients, compared to 85 percent of doctors who accept privately-insured or Medicare patients.

“Virtually all doctors who practice in community health centers, which are a key source of primary care in low-income communities, accept new Medicaid patients,” the report said. “Well over half of Medicaid beneficiaries are enrolled in contracted managed care plans, which are responsible for ensuring adequate provider networks and access to care for their Medicaid members.”

Another recent study showed that appointment access for Medicaid patients has increased by 5.4 percent since 2013. While privately-insured and Medicare patients still enjoy a marginally faster process for obtaining an appointment, Medicaid patients are seeing improvements that are nearly on par with Medicare and private insurance patients.

READ MORE: 2017 Patient Engagement Requirements for MACRA, Meaningful Use

Medicaid patients are also seeing improved outcomes due to this better and more equitable access to healthcare, per data from the Harvard T. H. Chan School of Public Health.

Certain benchmarks needed for Medicare, Medicaid

Medicare is a federally-sponsored health plan, and Medicaid is sponsored in part by the federal government and then administered by individual states. As such, these two healthcare payers must answer to a set of national benchmarks as a part of the shift to value-based reimbursement.

Some value-based payment models, such as accountable care organizations (ACOs), rely on patient-centered care to fuel success. ACOs require providers to continually communicate with their patients to help fill in care gaps and provide coordinated care.

Providers also face many technology-focused patient engagement requirements. Under Stage 2 Meaningful Use, the stage for which many eligible hospitals are reporting, participants must report at least one unique patient using view, download, and transmit capabilities with their health data.

Additionally, eligible hospitals must answer a yes or no question about enabling secure direct messaging with patients.

READ MORE: Digital Patient Engagement Measures Aid Clinician Improvement

Under Stage 3 Meaningful Use, which is mandatory for all eligible hospitals starting in 2018, patient engagement measures will be consolidated into a more streamlined set of requirements. The final rule states:

In the Stage 3 Patient Electronic Access Objective, we proposed to incorporate certain measures and objectives from Stage 2 into a single objective focused on providing patients with timely access to information related to their care. We also proposed to no longer require or allow paper-based methods to be included in the measures (80 FR 16753) and to expand the options through which providers may engage with patients under the EHR Incentive Programs. Specifically, we proposed an additional functionality, known as application programming interfaces (APIs), which would allow providers to enable new functionalities to support data access and patient exchange.

Stage 3 Meaningful Use also has a 25 percent patient engagement benchmark.

Under MACRA, which serves as a meaningful use replacement for eligible providers (now called eligible clinicians), participants must engage in either Advanced Alternative Payment Models (APMs) or the Merit-based Incentive Payment Systems (MIPS).

Under MIPS, eligible clinicians face a number of patient engagement requirements. These requirements include:

  • Allow one unique patient view, download, and transmit capabilities with their health data
  • Allow one unique patient access to their health data via an application programming interface (API)
  • Supply patient-specific educational materials to one unique patient
  • Extend one unique patient view, download, and transmit capabilities, with that patient then transmitting the data to a third-party provider
  • Send or answer at least one secure direct message with one unique patient
  • Collect patient-generated health data from one unique patient
  • Send or receive a summary of care from a third-party provider for one unique patient

Reporting for MACRA began at the start of 2017.

Private insurers set their own engagement benchmarks

While there are fewer concrete patient engagement requirements associated with private insurance and employer-sponsored plans, private insurers do conduct their own individual efforts for more patient-centered care.

In many cases, these strategies center on consumer choice and the payer-patient relationship. When patients have the freedom to purchase their own health plans – either on the individual exchanges or from a set offered from an employer – payers need to make their packages appealing to shoppers.

“Insurers, providers, and other established industry players will be forced to adapt today to provide consumers with the choices, engagement, and experiences they demand if they have any hope of keeping their turf tomorrow,” said a June 2016 PwC report.

A significant part of patient-centered care for private healthcare payers is increasing price transparency and clarity around cost-sharing. As patients increasingly adopt high-deductible health plans, they are bearing more financial responsibility from their payers.

Payers must respond by being clear about how much patients owe and other details of the insurance package.

“The first step is that the regulators would make available this data that allows the consumer to understand what their cost-sharing responsibilities would be under different health plan choices,” former HHS Director Joel Ario said in a previous interview with

Steve Auerbach, Chief Executive Officer of Alegeus, a healthcare consultancy group added that payers can also guide patients in where to reduce healthcare costs.

“What we see more of the innovative healthcare companies doing is simplifying the experience. This means making it easy for the consumers to understand how to save better and how to spend more efficiently. Most of the industry that we see is actually starting to integrate and simplify,” Auerbach told in a separate interview.

Private insurers also create their own initiatives to engage patients in care. Health plan rewards or discounts may impel patients to improve their health through regular wellness techniques (i.e. better diet or gym membership).

Many employer-sponsored plans also create employee wellness contests. Beneficiaries may work to meet a certain weight goal or compete in a corporate fitness challenge to receive individual and group benefits from the payer.

“Several [Blue Cross Blue Shield of North Carolina] client groups incentivize or penalize employees who achieve a certain body mass index or who remain tobacco-free,” wrote Brian J. Caveny, MD, JD, MPH, in a 2015 report in the North Carolina Medical Journal. “Others incentivize members who engage in BCBSNC wellness programs, disease management, or nurse case management.”

While the road to more patient engagement may entail varying requirements between private and public payers, the end goal is still the same: empower patients with the data and mechanism necessary to improve and manage their own health. Regardless of specific requirements based on insurance, providers must still use their unique interpersonal skills and empathy to deliver patient-centered care.


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