HR1 Is Stress Testing Medicaid Performance Metrics and Exposing a Failure in Engagement

In Medicaid, the most important interactions rarely show up where performance is measured.

They happen in apartments where phones have been disconnected, in cars parked behind grocery stores, in households juggling multiple jobs and caregiving responsibilities, and in moments when a letter from a health plan feels indistinguishable from every other piece of official mail that promises help but delivers confusion. These are the points at which engagement is either built or lost — and where the system’s performance metrics quietly begin to diverge from reality.

This disconnect has become one of the defining operational challenges facing Medicaid plans. What was once considered an under-the-radar risk is no longer subtle. It is now actively shaping plan performance, provider behavior, and financial outcomes across Medicaid systems.

Most Medicaid performance frameworks assume a basic premise: that members can be reached, engaged, and guided into care through conventional channels. Calls, texts, portals, mailings, and reminders form the backbone of outreach strategies tied to quality metrics and incentive programs. But that premise breaks down for a substantial portion of the population plans are measured against.

In many markets, a significant share of members is effectively disconnected from traditional care pathways. These members have outcomes that disproportionately influence quality scores, utilization trends, and downstream costs. They are also the least likely to respond to automated outreach, comply with documentation requirements, or maintain continuity of care amid housing instability, food insecurity, behavioral health challenges, and frequent eligibility disruptions.

Nonetheless, performance metrics continue to apply uniformly.

What follows is a compounding cycle. Plans invest heavily in outreach efforts that often don’t quite reach the people who matter most. Quality gaps remain open — not because care was unavailable, but because engagement never took hold. Financial penalties follow. At the same time, disengaged members reappear in higher-cost settings such as emergency departments and inpatient units, driving utilization up just as incentive revenue declines. Providers absorb more uncompensated care and administrative burden. Hard won trust erodes further. The next round of outreach becomes even less effective.

The result is a quality trap: performance metrics tied to engagement that the system itself struggles to achieve.

HR1 has intensified this dynamic. With tighter margins, more frequent redeterminations, and heightened scrutiny on quality performance, Medicaid plans are no longer debating whether engagement matters — they are searching for any edge to stabilize financial performance.

In this environment, engagement is no longer a “nice to have.” It is one of the few remaining levers plans can pull to influence both quality outcomes and cost trends at the same time.

Digital quality reporting has further diminished plans’ ability to correct gaps after the fact. If care isn’t documented accurately and in real time, it often doesn’t count. At the same time, more frequent eligibility redeterminations are disrupting care relationships, pushing members on and off coverage. When people return, they’re often sicker, care plans must restart, and hard-won trust has eroded. Still, quality metrics continue to be applied consistently — even as continuity of care does not.

From the outside, this looks like underperformance. From the inside, it looks like a system measuring outcomes without accounting for whether engagement ever occurred.

What consistently changes outcomes is not another reminder or portal enhancement, but human presence. Field-based, relationship-driven engagement reaches members where traditional systems fall short — helping people understand benefits that often feel abstract, reconnecting them to primary and behavioral care, and staying involved through follow-up and transitions. Practical barriers such as transportation, documentation, and scheduling are addressed before they quietly derail performance measures.

Equally important, this approach provides continuity in a system that increasingly lacks it. When coverage is disrupted, appointments are missed, or trust in institutions is low, consistent human engagement becomes the stabilizing layer. It doesn’t instantly fix performance metrics — but it makes them achievable again.

Over time, the effects compound in the opposite direction. Engagement improves. Documentation becomes more consistent. Care gaps close earlier, not at year-end. Avoidable utilization declines. Providers experience less friction. Plans regain some control over outcomes they are held accountable for.

This is not an argument against measurement or accountability. Medicaid must demand results. But performance metrics are only as meaningful as the system’s ability to reach the people they depend on. When engagement is fragile or absent, metrics do not drive improvement — they amplify dysfunction.

If Medicaid performance systems continue to measure outcomes without accounting for engagement, the consequences will keep compounding: financially for plans, operationally for providers, and clinically for members. Interrupting that cycle requires more than better dashboards or tighter benchmarks. It requires investment in the human infrastructure that makes engagement possible in the first place.

Until the system can reliably reach the people it measures, performance will continue to reflect disconnection rather than care — and the gap between what Medicaid expects and what it can realistically achieve will only widen.

Photo: designer491, Getty Images

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