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By developer
June 30, 2020
Health Services
Patient Engagement
Ontrak Veteran Health

The Overlooked Patient: How Payers Can Identify, Engage, and Treat the Vulnerable Populations Not Participating in Their Own Care

The Overlooked Patient

How Payers Can Identify, Engage, and Treat the Vulnerable Populations Not Participating in Their Own Care

An often overlooked and underappreciated aspect of the U.S. healthcare system is that a substantial number of Americans are not participating in their own care, despite having access through health insurance.

The reasons why some people may not engage in their healthcare are myriad and complex. Challenges can stem from a range of causes, ranging from a mistrust in the medical system to social determinants of health such as transportation, food, or economic insecurities, to a lack of health literacy – all of which create voluntary or involuntary barriers to certain individuals seeking or obtaining proper medical care. Sometimes labeled “careavoidant,” this population may not engage in medical care even at times when they suspect it to be necessary, when they are experiencing major health problems, and when they are showing signs of symptoms, according to a study in the Journal of General Internal Medicine.

Further, lack of participation is often intensified among people experiencing behavioral health issues, such as anxiety, depression and substance abuse, which can create additional challenges that result in both increased risk for and worsening of chronic medical conditions.

For the U.S. healthcare system overall, the health plans that cover these members, and individuals within these populations, the consequences of not participating in care can be dire. For these individuals and their families, foregoing needed medical care may result in late detection or treatment of disease, reduced survival, increased costs, and potentially preventable human suffering. For health plans, members’ lack of engagement in their care can lead to untreated chronic conditions growing worse over time, creating numerous preventable costs through drivers such as avoidable emergency department and inpatient stays. Populations with behavioral health conditions and medical comorbidities can inflate healthcare costs by up to 6.2 times – with little to none of those dollars spent on behavioral care. This can result in as much as $68B in avoidable annual costs, a figure that is growing by upwards of 7% annually by some estimates. Additionally, according to a 2018 study, more than half of Americans do not understand how to navigate the current healthcare landscape because it is so complex, creating an estimated $4.8 billion annual administrative cost burden for payers.

“More than half of Americans do not understand how to navigate the current healthcare landscape because it is so complex, creating an estimated $4.8 billion annual administrative cost burden for payers.”

growing by upwards of 7% annually by some estimates. Additionally, according to a 2018 study, more than half of Americans do not understand how to navigate the current healthcare landscape because it is so complex, creating an estimated $4.8 billion annual administrative cost burden for payers.

While the reasons that so many Americans are not participating in the healthcare system are complex and difficult, the opportunity to better serve those individuals is significant and entirely within reach. Ontrak, Inc., a behavioral healthcare company, applies advanced analytics to identify patients with untreated behavioral health issues that lead to high costs for health plans and then provides expert coaches who help patients overcome barriers to care. Leveraging our understanding of the interplay of systemic and personal barriers our members experience, we:

  1. Identify the drivers of increased utilization and help members with behavioral health and chronic conditions, get the medical and psychiatric care they need
  2. Engage every individual using ongoing motivational interviewing to build trust, uncover and address barriers and align to member goals to begin their journey to better health
  3. Treat members in up to a 52-week evidence-based program tailored to individual needs, including a dedicated care coach to help navigate the healthcare system and a community care coordinator to solve for social determinants of health

Ontrak’s approach enables our health plan partners to remove barriers to their members’ participation, increase coordination and health literacy, and engage vulnerable members to improve their health outcomes while significantly lowering costs.

Ontrak’s approach enables our health plan partners to remove barriers to their members’ participation, increase coordination and health literacy, and engage vulnerable members to improve their health outcomes while significantly lowering costs.

The leading causes of lack of participation in care

When studying why certain individuals are not engaging in their own healthcare, two broad themes emerge and intersect in a unique way: systemic issues and individual factors. Regardless of the reason however, the result is a lack of trust in the medical system that further keeps some members from engaging in their own healthcare.

Many members have well-founded reasons for the resulting avoidance of care. The healthcare system is often not well-equipped to deal with problems related to behavioral health and social determinants of health. Indeed, the nation’s healthcare system is challenging to navigate even for those who are motivated, and even more so for those who don’t have high health literacy and must additionally overcome medical bias.

Broadly, systemic issues that act as barriers to care can be grouped into three categories: access, availability and adequacy. For example, some members lack access to the care they need because facilities are too far from their home or difficult to get to. Other members may have access to care but struggle with availability. Finally, some members may experience shortcomings with the adequacy of care they receive, meaning their health outcomes do not improve over time despite obtaining recommended care.

Additionally, many systemic issues with the medical system involve real and perceived “hassle,” such as the time and effort required to make appointments, long wait times and the desire to avoid spending time around sick people.

Similarly, personal issues that serve as barriers to care are diverse and may include fear, past negative experiences and socioeconomic concerns. People with behavioral health conditions often have diseaserelated reasons such as low motivation, or fear of the stigma associated with behavioral health issues. Others fear confronting the unknown or a difficult to face diagnosis such as SUD or may hope that their medical issues will simply improve or disappear over time.

Many patients who do not engage in their own care have experienced negative interactions with the healthcare system in the past, rendering them reluctant to participate again. For example, some have experienced medical bias or misdiagnoses of past conditions and have learned to mistrust physicians and healthcare organizations, in general.

Many personal concerns involve negative experiences communicating with doctors and other medical providers. This may stem from some physicians having difficulty communicating with people with mental health conditions or recognizing when a behavioral health condition is present.

Finally, social determinants of health issues play a significant role in creating barriers to care for some members. These issues may encompass factors such as transportation barriers and insecurity involving employment, food and housing. Economic barriers, in particular, can deliver a great impact on wideranging aspects of health. For example, a report from the Commonwealth Fund found that, compared to their higher-income counterparts, relatively healthy low-income people are more likely to have poorer selfreported health and greater health risks, have more mental health problems, have greater social needs or concerns, have more limited access to care and use less preventive health care.

Social determinants of health issues—such as transportation barriers, food insecurity, unemployment and lack of adequate housing—play a significant role in creating barriers for some members.

Behavioral health barriers

The Substance Abuse and Mental Health Services Administration’s (SAMHSA) 2017 National Survey on Drug Use and Health revealed the extent of the unmet need for mental health services among U.S. adults. In that year, an estimated 13.5 million adults, or 5.5% of the nation’s adult population, had a perceived unmet need for mental healthcare at any time in the prior year, a figure that includes the 6.5 million adults who did not receive any mental health services in the prior year. Untreated behavioral health issues can exact a heavy toll on individuals and society, leading to lower quality of life, worse physical health and lower worker productivity, according to a study published in the Primary Care Companion to the Journal of Clinical Psychiatry.

Often, treatment for physical and behavioral health issues remains siloed, resulting in a “one-size-fits-all” approach that renders treatment less effective and leads to confusion among members. For example, the SAMHSA study found that the second-most frequently cited reason for not receiving behavioral healthcare services among adults with serious mental illness was that they did not know where to go for services.

The most-frequently cited reason for not obtaining behavioral healthcare services was cost, while other reasons included stigma associated with treatment such as neighbors or community members having a low opinion and fear of others finding out. Notably, simply having insurance coverage is not sufficient to guarantee that members will seek behavioral healthcare treatment, as many respondents to the SAMHSA study observed that their health plans did not provide adequate or any coverage to pay for these services.

Finally, it must be acknowledged that racial inequality has long played a substantial role in limiting behavioral healthcare treatment in affected populations. For example, a study in Psychiatric Services revealed that non- Hispanic Blacks, Hispanics, and individuals in the “other” race category experienced relatively lower odds of receiving treatment for behavioral health issues compared with similar groups. Among Blacks and Hispanics, frequently cited reasons associated with foregoing behavioral health treatment included factors such as distrust of health providers, a perception of low efficacy of treatment, internalized stigma associated with mental disorders, and loss of income as a result of taking time off from work, according to the study.


Non-engagement and the COVID-19 pandemic

The COVID-19 pandemic has created new complications and challenges across the healthcare system, but especially for behavioral health. The pandemic has heightened many existing barriers to care such as economic stress, food insecurity, substance abuse and the inability to access community services.

Further, COVID-19 has led to greater destabilization of chronic conditions by reducing access to care. Many provider offices shut down entirely or reduced capacity as the pandemic began sweeping across the U.S., and many members have avoided obtaining care in-person out of fear of contracting the coronavirus. It is likely that the lack of care will exacerbate chronic diseases such as chronic heart failure and diabetes.

According to a May 2020 Kaiser Family Foundation tracking poll, nearly half of Americans reported someone in their family skipped or delayed getting some type of medical care due to the pandemic, including 11% who say the person’s health worsened as a result. Among those who said they or a family member skipped care, most said they plan to get care in the next three months, but about a third said they plan to wait longer or forego care entirely. Barriers to obtaining care during the pandemic may be even worse for rural Americans, as declines in volume may lead to additional rural hospital closures.

For payers seeking to engage with members who are not participating in their care, the pandemic has stretched thin some resources, limiting the field work care coordinators and coaches are able to perform and hampering the ability to establish strong connections with members.

The number of visits to ambulatory practices declined nearly 60 percent by early April. Since that time a rebound has occurred, but the number of visits is still roughly one-third lower than what was seen before the pandemic.

During the COVID-19 pandemic, many members have avoided obtaining care in-person out of fear of contracting the coronavirus. It is likely that the lack of care will exacerbate chronic diseases such as chronic heart failure and diabetes.

Even during non-COVID times, payers have generally struggled to engage with members that do not participate in their care. The episodic care that most patients seek is not adequate to establish a basis for engagement that leads to behavior change.

The challenge for payers is being proactive in identifying members before their conditions become chronic and more costly, and many members are not responding to plans’ efforts to engage in programs that could improve their conditions.

Payers experience difficulty engaging with nonparticipating populations for a variety of reasons, including lack of time, lack of resources, prohibitive policies and an inability to understand how to connect with these members. The challenge for payers is being proactive in identifying members before their conditions become chronic and more costly. But even when health plans identify members who are not getting better, many members are not responding to plans’ efforts to engage in programs that could improve their conditions.

Ontrak adopts a unique approach to reach this non-engaged population, starting with recognizing the drivers of care avoidance and identifying populations that could benefit from a more hands-on approach to their care.


Ontrak’s approach: Step one – Identify

This first major component of Ontrak’s approach is to identify the members who can both benefit from greater engagement and generate cost savings for payers. Leveraging advanced analytics and a variety of predictive data sources, Ontrak’s proprietary algorithms analyze member data such as past claims, diagnosis codes and prescription history to determine, for example, the likelihood of a member experiencing a behavioral health challenge. Then, algorithms parse the data to determine a member’s “impactability,” or, their likelihood that health outcomes and cost can be improved through better engagement and treatment.

For example, consider a hypothetical scenario involving a member who has Type II diabetes. In the past year, claims showed that this member experienced several emergency department and inpatient visits due to insulin shock. After each admission, the member received support from the health plan’s care team, yet the pattern persisted. Unknown to the hospital and health plan, the patient also suffers from acute pancreatitis — a key indicator for alcohol use disorder.

Ontrak’s solution can train a machine-learning algorithm to “score” this member based on behavior as having a high probability of a substance use disorder and flag the member as a candidate for targeted outreach. In this scenario, the member’s alcohol abuse likely would have otherwise remained unknown to the health plan, resulting in a future of escalating costs and unsuccessful interventions that were not targeted toward the member’s most significant health issue.


Ontrak’s approach: Step two – Engage

A key component of Ontrak’s approach is to build trust with members by starting with their perceived challenges, including their health, barriers to care and other factors keeping them from accessing the system. This starts with meeting members where they are, making them comfortable and speaking to them as equals. This approach takes a holistic view of a person, rather than simply focusing on their medical condition. Ontrak goes deeper than other programs to understand the barriers preventing people from getting the care they need at the individual and population levels.

The process begins with an engagement specialist calling a health plan member who has been identified as impactable. The engagement specialist must first educate the member about the Ontrak program and why they are receiving the call to begin building trust and get the member interested in having a conversation about how to improve their quality of life, as many members may be unaware that they’re having issues with physical or behavioral health.

As the partnership with the member proceeds, engagement specialists adopt an omnichannel approach to communication, meaning they use whatever communication option is most preferable to the member – email, texts, phone calls, direct mail or other options.

A key feature of the program is for the engagement specialist to remain focused on the emotional, as opposed to medical, component of the member’s health. This begins by assessing the member in relation to Maslow’s hierarchy of needs. If the member is experiencing food or housing insecurity, for example, managing his chronic condition is likely not his first priority. By engaging at a granular level of basic human needs, the engagement specialist can establish the beginning of a relationship with the member, helping convince him to continue the partnership.

Some members enroll in the program as a result of the first call, while others require persistence and convincing. For members who do not indicate initial interest, Ontrak’s engagement specialists continue to reach out once a month. Members are only dropped from outreach lists when they enroll in the program or request to no longer be contacted.

An essential part of Ontrak’s approach to engaging with members is motivational interviewing, which is designed to help members figure out the methods that will most help them change their lives. Member engagement specialists facilitate discussions, but members remain in control.

Member engagement specialists are trained in strategic techniques to help patients open up and gradually gain more self-awareness, starting by asking members to discuss how they think they will best be able to address their health issues. Engagement specialists then proceed to questions intended to facilitate friendly conversation and enable the discussion to develop organically. Importantly, engagement specialists do not reveal that they have detailed data and analytics on the member’s medical history.

Engagement teams frequently and periodically receive training on how to best engage with members, including how to identify key words and phrases that indicate a member is seeking help without requiring the member to explicitly ask for it. This training enables engagement specialists to better identify behaviors associated with suicide ideation, anxiety, depression, substance abuse and other behavioral health issues.

Engagement specialists employ open-ended questions, as opposed to “Yes-or-no?” questions, to elicit more productive conversations. Binary questions or externally dictated goals help in gathering information but do little to inspire behavior change. Dr. Julia Wright, Chief Medical Officer of Ontrak, notes, “Our specialists have found that open-ended questions used as part of motivational interviewing help inspire members to achieve their own goals, as opposed to the goals someone else has set for them.”

Motivational interviewing is a well-known cognitive behavior therapy tool to help individuals engage in their care. More than just a “technique of doing counseling,” motivational interviewing is a “way of being with a client,” according to SAMHSA. Among motivational interviewing’s greatest benefits is its ability to help patients resolve the ambivalence that prevents them from realizing personal goals.

The engagement specialist’s goal in the motivational interviewing process is to elicit self-motivational statements and behavioral change from patients, as well as to create “client discrepancy” to enhance motivation for positive change. Ultimately, motivational interviewing is intended to “activate the capability for beneficial change that everyone possesses,” according to SAMHSA.

Over time, Ontrak’s approach leveraging motivational interviewing helps build members’ trust, which facilitates conversations moving from concerns about physical health to behavioral and emotional health challenges. By employing these motivational interviewing techniques, engagement specialists help members develop greater comfort in identifying and discussing issues that make them feel vulnerable, which are usually the same problems that lead members to non-participation in their care and excessive costs for health plans.

Ontrak’s approach: Step three – Treat

In the treatment component of Ontrak’s approach, dedicated care coaches – including certified health coaches, LPN’s, and RN’s – coordinate care through the Ontrak program, personalizing steps based on evidence-based approaches, removing barriers to access, connecting members with the care they need and keeping them engaged in the process. One important differentiator of Ontrak’s approach is its duration: The program lasts up to 52 weeks, while offering coaching that is personalized to each member’s specific medical and behavioral health needs.

A BETTER WAY Ontrak’s program lasts up to 52 weeks, allowing coaches to meet members where they are in their health journey and to build relationships – and trust.

Because we start with the assumption that every member is to some extent not ready to change or is ambivalent about behavior change, we adopt a coaching-focused – as opposed to a case management – approach. Experience has proven that most members who don’t participate in their care can be repelled by the traditional case management approach, which is more transactional, as opposed to the relationship-based nature of the coaching approach, which is predicated on sustained engagement and buoyed by trust.

Ontrak coaches use motivational interviewing techniques to build trust and rapport with members. They live by the mantra, “What matters to the member is more important than what’s the matter with the member.” The primary goal of a coach’s first call with a member is simply to have a second call. After discussing the member’s own concerns, barriers and needs, coaches build on that trust and rapport to help members set goals to address the behavioral health issues that may be negatively contributing to their overall health.

Once the coach has identified what is important to a member, the coach works to connect the member with an appropriate clinician who can help address their medical and behavioral health needs. When needed, coaches also help connect members with community coordinators who identify resources to assist with barriers to care related to social determinants of health such as arranging transportation, food scarcity, language or literacy issues, or economic challenges. Ultimately, Ontrak coaches aim to establish strong member relationships that enable them to participate in their own care and achieve sustainable behavior change.

Ontrak’s approach has been proven to generate engagement twice as high as approaches focused solely on care management. Importantly, Ontrak’s method generates as much as 50% cost savings to payers, in part through lower rates of member visits to the emergency department and inpatient hospital stays. The approach has lasting effects, measuring durable impacts over two years post-graduation. Graduation outcomes include: 1) durable behavior and lifestyle changes, 2) resolution to social and member-level barriers to care, and 3) engagement with a primary care provider and the health plan.


Our approach has been proven to generate engagement twice as high as approaches focused solely on care management, generates as much as 50% cost savings to payers, and provides lasting and durable impacts post-graduation.


A better way to achieve behavior change and cost savings for non-participants

The reasons members may not engage in their care are virtually as numerous as members themselves, but most can be categorized into systemic issues, such as access, availability and adequacy, or personal issues, such as negative past experiences with the healthcare system. The COVID-19 pandemic has exacerbated these issues underlying the U.S. healthcare system and is likely to fuel an even greater rate of patients who do not engage in their own care.

The ramifications of this lack of engagement suggest significant challenges ahead for participants across the entire healthcare spectrum. For members, non-engagement often leads to preventable health problems growing more acute over time and additional hardships and adversity as a result of late disease detection. For payers, the inability to engage members in their care directly induces excessive and spiraling costs as members continue to utilize expensive medical services that may not ultimately address the underlying behavioral health issues that are the primary cause of their lack of engagement.

Ontrak’s approach to identifying, engaging and treating these patients relies on advanced analytics to help payers target high-utilization members who may also benefit from interventions that enable them to pinpoint the barriers that prevent them from care engagement. After identifying these barriers, Ontrak’s team of engagement specialists and coaches utilize evidence-based motivational interviewing techniques to establish productive relationships that help members set their own goals along the journey toward better health. Once member trust is gained, Ontrak’s coaches and care coordinators enroll members in up to a 52-week program that connects them with the resources they need to address and solve their underlying behavioral health conditions that have generated avoidable costs.

To change the behavior patterns of members who are not participating in their own care – regardless of the reasons – the best option for payers is to target, engage and treat these individuals with persistence and encouragement that meets each member wherever he or she is on their health journey.