New Membership Preparation From a Clinical Perspective

How do plans get ready for new membership as the new enrollment period starts?

When you are trying to plan for the future at times it is best to look back at the past….past data, past experiences, trends and your past mistakes as well.

As AEP rolls around it’s time to look back at the clinical picture of plan year 2018 data. If you are keeping the same service areas, or if you are entering counties with like populations, what did your last plan year’s data tell you? Did you anticipate the population attributes that contributed to increased utilization costs?

One exercise to consider is to isolate all of the members who were new to your plan last year, by county, and look back at their inpatient, pharmacy and outpatient specialty physician use. Then take this data and categorize by disease state or diagnosis, age/gender bands and plan type.

Consider to then ask the following questions:

  • Did we analyze, on a first quarter/monthly basis, the new Rx fills for this new membership for clues to the member early care management intervention?
  • Did the care management team reach out to and successfully engage the member in care management strategies?
  • Did the care management team identify any additional information that could have been beneficial for prevention of hospital admissions and if so, how was the information used to influence member behavior?  Was the information shared with the PCP?  ? (hopefully to the PCP)
  • Was the comprehensive medication review conducted timely and did the review reveal new care management clues?
  • Did we see patterns of underutilization on the provider side based upon the type of prescriptions filled?
  • Did we see a member with high utilization of a specialty provider without establishing a PCP?

Taking into consideration your past plan year data trends, especially with similar populations in the same service area/subsidy classification and benefit structures can give you clues of what may be in your future for managing new members  from a clinical program perspective.

If you have the opportunity to use a tool that prospectively predicts social determinant of health attributes based upon consumer behaviors, this will be a great data overlay to the above.

Many plans miss opportunities with new members because, well, they are new and if they don’t hit the hospital doors or have high claims volume early on, they stay on the outside of what care support or interventions are possible to manage their care.  To help prepare for the upcoming year, we recommend that plans start analyzing member information early on, and then ongoing to identify ways the plan can help members use the benefits and network to their benefit and your cost savings.


Jane Scott
Jane Scott

Jane Scott is Senior Vice President of Population Health Management and Clinical Innovations at Gorman Health Group (GHG). In this role, she is responsible for leading GHG’s Clinical Innovations practice area. Jane brings GHG clients 37 years of experience in healthcare as one of the industry leaders on the topics of the Centers for Medicare & Medicaid Services (CMS) Special Needs Plans (SNPs), development and implementation of Models of Care (MOCs), as well as the Star Ratings Quality Bonus Payment Program. Her experience expands to the areas of quality improvement (QI), utilization and medical management, claims operations, and provider/associate education.

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