02
translation: Giving people exactly what they came for is everything.4. Lists are expensive to maintain
Someone searches for an answer via Google.
They read a post that solves their problem (and features our tool) on our blog.
They sign-up for a trial.
Though our data shows the notifications perform better than emails, the overall reach is still quite low. Which is why we rely upon several other marketing methods to make sure our content reaches our audience.
3. Opt-in tricks may do more harm than good
Ok, you may still be wondering:
But why not, potentially, make your list even bigger? Why not use opt-in tricks?
As previously mentioned, our CEO dislikes marketing “tricks” because they are disingenuous by design. But he also questions their effectiveness.
For every visitor who subscribes via a pop-up, you might annoy someone else away. Unfortunately, there is no definitive way to track how many potential customers are lost this way.
However, I often come across case studies like this one about food blogger Nikki McGonigal.
The foodie procured 1,375 per cent more subscribers with a lightbox pop-up than a sidebar opt-in, during an 8-month period. Clearly, the strategy sometimes works with elegant execution.
However, that’s not what many online marketers seem to advocate. After receiving three pop-ups in quick succession, SEO Dan Petrovic said he abandoned marketer Neil Patel’s site in frustration.
He shared his experience on social media with a post titled “How to lose the audience in three easy steps.”
Below are the pop-ups Petrovic is referring to in his post:
Here’s the thing — Patel is marketing to a specific segment of marketers, and he’s proven through testing that these techniques work on them. That doesn’t necessarily mean they will work on your audience or mine.
However, I think Ahrefs could improve its opt-in strategy with something in between the two previous examples.
Right now, we utilize a “classic” subscriber form located at the bottom of each post. I suspect these forms are often overlooked, due to their widespread usage.
After publishing this post, we’ll be experimenting with something more eye-catching — a discrete, slide-in form. However, the opt-in won’t appear until the reader reaches the bottom of the article.
Could we entice readers with a freebie in exchange for providing their email addresses? Yeah, but we don’t want them to feel like “just another number” in our email lead nurturing sequence.
Our goal is to maintain an email list of individuals who voluntarily signed up to receive notification of newly published articles — not a downloadable bribe.
Setting and fulfilling clear expectations builds trust, and trust translates to sales.
Our blog brings us, new customers, because we put 110 per cent effort into creating content that solves their problem while demonstrating the power of our platform.
With this in mind, we don’t want to interrupt the reading experience we worked so hard to create. A pop-up requires someone to leave the site, check their Inbox, confirm their email address and refocus.
Considering how much time and money we spend creating articles, why would we, voluntarily, direct potential customers away?
The majority of our business comes from word of mouth. Our readers regularly recommend our content on platforms like Reddit, LinkedIn and Twitter.
This wouldn’t happen if we distracted them with enticing freebies, before unexpectedly inundating them with “lead nurturing” emails.
translation: Giving people exactly what they came for is everything.4. Lists are expensive to maintain
Finally, the ultimate downside of “growing your list at all costs” might be the cost of maintaining it. Email service providers like Mailchimp commonly offer to scale price plans based on “number of emails sent.”
This is a really bad deal considering less than 30 per cent of subscribers is opening the average business’ emails. Check out this notification we received recently because we ran out of credits:
Fail to set-up “double opt-in” — where subscribers must click on an emailed confirmation link before joining — and you’re, potentially, leaving even more money on the table.
Why doesn’t Mailchimp charge based on “number of emails opened?” I’m not sure, but paying for something that consistently delivers low ROI should always be questioned.
Again, the money isn’t on the list
It’s in our ability to solve problems with valuable content that promotes our product while drawing organic search traffic. Right now, our buyer’s journey looks like this:
This simple sequence works because the person wants to put into action what he or she just read about.
Engaging in email funnel optimization would add two extra steps to the journey — email confirmation and additional email engagement — that would prolong the visitor from their main objective after reading the article: Playing with the software!
What about you? How do you approach to list building? What sort of results have you experienced with pop-ups, sliders and more?
Let me know in the comments below.
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03
An increase in mental-health transports by Tucson police.
More petitions for court-ordered mental-health evaluations, to determine if a person is a danger to one’s self or others and requires court-ordered treatment.
And a rise in inpatient psychiatric hospital days for patients with mental illness at least one large behavioural-health agency.
In response to a public-records request, the Tucson Police Department released data showing mental-health transports to the Crisis Response Center or psychiatric hospitals increased from 2,224 in 2013 — the earliest reliable data-year — to 3,366 in 2018.
Three-and-a-half-years later, the insurer — now known as Arizona Complete Health — has released little patient-outcome data that could shed light on how its members with behavioral-health needs have fared since it took to charge.
Data obtained by the Arizona Daily Star shows trends since 2015 that are worrisome to some Tucson providers and advocates.
With many factors at play, including an ongoing opioid crisis, it’s impossible to nail down a single cause of increased reliance on Tucson crisis services. And greater utilization of the Crisis Response Center could be a positive trend, as awareness of the CRC as an alternative to jail continues to grow among law enforcement.
Clarke Romans, executive director of the National Alliance on Mental Illness Southern Arizona, or NAMI, said there’s been too little data released publicly — by both Arizona’s Medicaid agency AHCCCS and Arizona Complete Health — to show what taxpayer dollars are paying for.
“There’s no accountability,” Romans said. “There’s just a giant cloud of mystery around how are people actually being served.”
DATA OBTAINED BY THE STAR
The Star requested patient hospitalization data from three of the biggest behavioural-health agencies in Tucson: La Frontera Arizona, COPE Community Services and CODAC. CODAC declined to share data with the Star. Rod Cook, CEO of COPE Community Services, said the agency’s data wasn’t consistent enough to ensure an apples-to-apples comparison between Cenpatico versus the previous regional behavioural health authority, which was the nonprofit Tucson-based Community Partnership of Southern Arizona.
A Star analysis of data shared by La Frontera found the number of psychiatric hospitalization days per 1,000 patients has been trending upwards since the fiscal year 2013, and the growth accelerated after the fiscal year 2016.
In the fiscal year 2012, the number of hospital days per 1,000 La Frontera patients was 561, compared to 1,169 in the fiscal year 2018, which ended in September. La Frontera had about 6,500 enrolled members that year.
In response to a public-records request, the Tucson Police Department released data showing mental-health transports to the Crisis Response Center or psychiatric hospitals increased from 2,224 in 2013 — the earliest reliable data-year — to 3,366 in 2018.
The crisis centre, which opened in 2011, has been a boon for law enforcement agents, who used to have to spend hours waiting at a hospital for a patient in crisis to be received.
Now, they can drop someone off at the centre and are received within 10 minutes, said Pima County Sheriff’s Department Sgt. Sean Payne, supervisor of the mental-health support team.
A March data-trends report from the Pima County Behavioral Health department shows the monthly average number of petitions for court-ordered evaluations increased from 147 in the fiscal year 2016 to a monthly average of 178 in the fiscal year 2018.
But Paula Perrera, department director, emphasized that the figures represent a small subset of the behavioural-health population, and she said it’s hard to draw any broader conclusions from the limited dataset.
“There are so many variables in the system. I don’t think we have a good enough handle on all of the data that we are in a position to opine,” Perrera said.
For Romans of NAMI Southern Arizona, the increase makes sense. He’s hearing more from people with mental illness, or their family members, that patients are being hospitalized or court-ordered repeatedly, in some cases after being discharged while they were still symptomatic and unstable.
“Within a very short time, they’re either petitioned (for court-ordered treatment) again or re-hospitalized,” he said. “It’s just like this treadmill sort of thing that these individuals can’t seem to get out of.”
Ongoing turmoil
Through its contract with AHCCCS, nonprofit Community Partnership of Southern Arizona managed the behavioural health system in Pima County for two decades before, in 2015, it lost its contract to Cenpatico Integrated Care, a subsidiary of publicly traded insurance giant Centene, based in St. Louis. (Cenpatico changed its name to Arizona Complete Health, effective in October.)
A chaotic October 2018 transition to integrated medical and behavioural health care for patients enrolled in the state’s Medicaid program — the Arizona Health Care Cost Containment System, known as AHCCCS — resulted in millions of dollars in unpaid claims, putting small, niche providers at risk of closure.
Under the new integrated care structure, Cenpatico — now Arizona Complete Health — is one of three insurers in Southern Arizona providing coverage that includes both physical and behavioural health care. The other two Southern Arizona integrated health plans are Banner-University Family Care and United Healthcare Community Plan. (Those with a designation of “serious mental illness,” as well as other groups like children in foster care, are still covered under the regional behavioural health authority system.)
Turmoil over the past few years has hindered access to routine care for patients, who are more likely to spiral into crisis and require hospitalization if they are unable to reach a case manager, reschedule an appointment in a timely manner or get their medications refilled, said Romans of NAMI.
“There’s just all kinds of little barriers that, for this set of patients, are big barriers,” Romans said.
CEO of La Frontera Arizona
Jordan Glenn / for the Arizona Daily Star
The behavioural health system has been strained in recent years, in part because management of how services are utilized has become less intensive, since that responsibility now falls to the insurers rather than front-line providers, said Dan Ranieri, CEO of La Frontera Arizona, one of the largest providers of behavioral health care and affordable housing in the region.
“You’re seeing a lot of (inpatient) services inflate,” he said. “We certainly don’t have any substantial data related to patient outcomes to know whether it’s a good thing or a bad thing. But we do know the system is more financially stressed than it’s been in 20 years.”
Recently, agencies have scaled back case-management services which, as of October, are no longer covered by default for patients with behavioural health needs. Some behavioural health agency leaders say that’s a reasonable change, as case management services aren’t necessary for every member.
But others say the loss of case managers is causing problems. Smaller programs are trying to fill that role when possible, helping members find stable housing, apply for food stamps or find transportation services, but they are not paid for that work, program leaders say.
“We find ourselves doing it without being reimbursed for it because people need it in order to be successful in a job,” said Dot Kret, founder of Tucson agency DKA, which offers free job training and coaching to people with disabilities or barriers to employment.
She’s noticed anxiety levels rising among clients with mental illness who no longer have their own case manager.
“People are forced into crisis situations that might not have occurred otherwise,” she said. “When people don’t have somebody to go to and they try to figure it out on their own, the frustration increases, the depression increases, the anxiety increases.
HCCCS AND CENPATICO: NO INTERVIEWS
HCCCS AND CENPATICO: NO INTERVIEWS
On Jan. 31, the Star requested an interview with Jami Snyder, the new director of AHCCCS, to discuss the behavioural health system in Southern Arizona. After cancelling a scheduled March 22 interview, an agency spokeswoman said Snyder had no time for a phone interview.
The Star requested any data AHCCCS has collected that could show how patients have fared in Southern Arizona since Cenpatico entered the market. AHCCCS spokeswoman Heidi Capriotti directed the Star to an AHCCCS webpage containing quality data reports, but the data that tracked patient outcomes over time used combined data from across the state; no measures were specific to Southern Arizona and Cenpatico.
Capriotti also directed the Star to an independent review of Arizona’s 2014 transition to integrated medical- and behavioural-health-career coverage for certain Medicaid populations, including those with a designation of “serious mental illness.” But this report, released in November 2018, studied only those with serious mental illness in Maricopa County.
On March 6, the Star requested an interview with Arizona Complete Health CEO James Stover. Spokeswoman Monica Coury said Stover had no time for an interview.
ACCOUNTABILITY AND DATA
During Cenpatico’s first contract year, which began in fall 2015, then-CEO Terry Stevens emphasized the importance of tracking providers’ data to show how patients are doing.
After a February 2016 interview with Stevens, the Star reported that “Cenpatico wants detailed reports on health outcomes for patients as part of its data-driven accountability system. It has been tracking the 20 per cent of patients who have the most severe bbehavioural-healthneeds to ensure they’re getting treatment. The (regional behavioural-health authority) is pushing for improvement in specific performance measures, such as reducing patients’ emergency room visits ... and it’s focusing on reducing repeat hospitalizations and recidivism among people with mental illness who serve jail time.”
In response to a Star inquiry seeking any data that would show how patients have fared in these or other measures since Cenpatico came to town, company spokeswoman Monica Coury released a four-page document that cited mostly short-term tracking of specific patient populations, such as those with serious mental illness who also have chronic obstructive pulmonary disease.
Between the first and last quarter of the fiscal year 2018, those patients were 57 per cent less likely to utilize the emergency department following a “team-based approach to disease management,” the document said.
Coury did not respond to follow-up questions seeking an interview about the data and requesting raw numbers to show how many patients were involved in the pulmonary disease study.
Coury’s document also cited a six-month, 72-person pilot project, in partnership with peer-run bbehavioural-healthagency Hope Inc. and Sonora Behavioral Health Hospital, aimed at reducing hospital readmissions.
Hope is run by “peers,” those who have personally engaged with the behavioural health system or have a family member who has. In the pilot, peer staffers worked closely with hospitalized patients after discharge to provide support and help reconnect them with outpatient services.
“It’s not rocket science; it’s just showing somebody that you care,” said Dan Haley, CEO of Hope. “That makes such a huge difference and that’s why peer support is so effective.”
Seventy per cent of the participating patients did not experience readmission between October 2018 and January, which was the first half of the pilot. Data from the second half isn’t available yet, Haley said.
Close coordination between behavioural health agencies and local hospitals used to be the norm, but that’s changed in recent years, said Cook of COPE Community Services. COPE used to have caseworkers meet their patients at the hospital, or at the Crisis Response Center, working to get them back into the community, with an eye toward long-term stabilization, he said.
But today, patients are no longer assigned to an agency that acts as a “health home” — they can go to whatever providers they want, resulting in more freedom of choice, but far less coordination of care. Now providers sometimes don’t even know what other services their members are receiving, Cook said.
And provider agencies are now reimbursed using a fee-for-service model, in which payments are based on the volume of services provided. Until recently, agencies got an upfront monthly payment per patient. That gave providers an incentive to closely manage members’ care and avoid intensive services like hospitals and instead help patients access more effective, and cheaper, wraparound outpatient services, Cook said.
“You’re looking for the most cost-effective and clinically appropriate place for them,” he said. “It’s almost never the hospital.”
Constant changes in payment structures under Cenpatico have challenged agencies’ ability to plan financially and provide services efficiently, said Susie Huhn, executive director of provider agency Casa de Los Niños.
“They kept changing the financial models every year, which really was hard on providers because then you have to change your practice model,” she said. “And you can’t change practice models in a year and have good outcomes.”
CRISIS RESPONSE CENTER
Tucson has a strong crisis network, including a nurse-triage crisis line, the Crisis Response Center and mobile crisis teams run by agencies like Community Bridges, said psychiatrist Margie Balfour, chief of quality and clinical innovation for Connections AZ, which contracted with Banner-University Medical Center in 2014 to take over management of the CRC.
Since 2015, the Crisis Response Center has seen a 7.7 per cent increase in adult visits and a 24 per cent increase in youth visits.
“The question is, is it a good thing or is it a bad thing? The answer is kind of both,” Balfour said. “Maybe some people aren’t doing well, are not getting their needs met” and go into crisis, she said. “But some of it is also the police becoming more comfortable and informed and skilled in engaging people and bringing them to treatment, instead of to jail.”
Ranieri of La Frontera Arizona said it makes sense that CRC visits are rising as awareness grows, but he said another factor is providers having fewer opportunities to head off crises before they occur.
“In the past, the interventions in the field were more likely to happen and people would never get to the CRC,” he said. “I don’t think people are going to the CRC inappropriately. I just think a lot of the aggressive interventions that might have gone on in the past just aren’t happening nowadays, for a host of reasons.”
Crisis services are a “gap-filler,” filling in when patients either aren’t connected with services at all, perhaps because they’re new in town, or helping patients who can’t reach their case manager or are having trouble getting their medication, Balfour said.
Addressing basic needs holistically, including safe and decent housing, is a fundamental service that crisis centres can’t address on their own, she said.
“You’ve got someone who’s depressed, suicidal, but they’re homeless,” Balfour said. “I’d be depressed and suicidal if I was homeless. ... People having a safe place to live is probably the thing we struggle the most with that’s out of our control, and that’s across the country.”
Detective Matt Golden left, and Sgt. Jason Winsky with the Tucson Police Department’s Mental Health Support Team meets at TPD headquarters.
Ron Medvescek / Arizona Daily Star
Sgt. Jason Winsky, the supervisor of TPD’s mental-health support team, said well-functioning crisis services are critical, but too few people are asking questions about the more routine outpatient services that can help people avoid a crisis in the first place. Media reports often focus on the initial crisis response, he said.
“There’s never media asking about, ‘Well, what about two months after the crisis? How is that person doing?’” he said. “It’s not the CRC’s job to make a 90-day plan for somebody.”
For Alexei Ruiz, 24, a stint in the Crisis Response Center was unhelpful. Ruiz grew up in the foster-care system, bouncing between foster homes and group homes, experiencing physical and sexual abuse. Ruiz, who has diagnoses of PTSD, panic disorder and bipolar disorder, said a series of difficult events last year became too much to bear, including the end of an abusive relationship, a manic episode and a near-eviction.
Ruiz, who prefers the pronoun “they” instead of “he” or “she,” said their needs were dismissed at the CRC because they were so much quieter than the other patients. Ruiz stayed there two days under observation but said everyone there seemed apathetic.
“I was hoping to get someone to talk to me so I didn’t feel like I was so out of control,” Ruiz said. “But I didn’t. I got slapped with, ‘You’re fine,’ and I took the bus home.”
Soon after, Ruiz was connected with a caseworker named Sam, and the caseworker’s compassion helped get Ruiz to stability. For about six months, Ruiz felt that someone understood what they had been through and understood their triggers.
“She was so involved in my life. She genuinely cared,” Ruiz said.
Alexei Ruiz
Nick Murray / Arizona Daily Star
Growing up in foster care, Ruiz said, it was common to tell one’s entire life story to a caseworker, getting retraumatized through the process, and then having to do it all again a month later with a new caseworker, due to high turnover rates in the child-welfare system.
div style="margin-bottom: 15px; vertical-align: baseline;"> A couple of months ago, it felt like déjà vu when Ruiz called to confirm an appointment and learned that Sam had been laid off.
“My support system was completely cut off,” Ruiz said.
THE “MERRY-GO-ROUND”
For families with loved ones experiencing mental illness or psychosis, trying to navigate the behavioural health system feels like “a merry-go-round,” said Tucson mom Louise Rempfer, a NAMI advocate for people with mental illness. She said her 28-year-old son has been struggling with mental health issues since experiencing a psychotic break in 2012 when he was living in California. He has been diagnosed with schizoaffective disorder.
Short-term stints in the CRC or psychiatric hospitals seem unending, and the stays rarely result in stability for any real length of time, she said.
“It’s just cyclical,” she said. She feels like there’s little coordination between his care providers and little respect for his family’s input: It recently took her almost nine months to get her son’s doctor to agree that he needed a medication change.
“I have to figure out ways to help him that are more resourceful than what the behavioural-health system’s offering,” she said. “We’re not getting to the root of this.”
div style="margin-bottom: 15px; vertical-align: baseline;"> Rempfer said in retrospect, her son was probably depressed as a child. She said he was always kind and gentle, working three jobs as a teenager: grocery store bagger, lifeguard and kids’ karate instructor. He’s creative and energetic, and it’s heartbreaking to watch him be traumatized over and over with each crisis, she said.
The bigger-picture problem in behavioural health care is that the system is too focused on treating surface-level symptoms, rather than addressing patients’ root challenges or trauma, Romans said. Early, wraparound intervention as soon as symptoms emerge would be key to improving crucial health metrics, like the dramatically reduced life expectancy for people with serious mental illness, he said.
“We are dealing with the symptoms of underlying illnesses,” he said. “Why don’t we spend the money up front, and actually we would save money, improve quality of life and life expectancy? What a concept.”
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