A key priority of high-performing payer operations is member-centered design. Best-practice payers are continuously striving to create the most convenient, simple, transparent, and cost-effective experience for their members. Those on the leading-edge target whole-member management via population health programs and care team design. They also set their sights on members’ end-to-end healthcare journey, although a significant gap exists between those taking this approach and the rest of the sector — fewer than 40% of payers currently track in-journey and end-of-journey performance.

On the aggregate, these moves are generating positive impact for members. However, without comprehensive and deliberate design, certain well-intentioned member engagement and care trends end up missing the mark:

• Omni-channel member communication offers easily accessible information and touch points, but is often disjointed or unclear, which can overwhelm and confuse the member
• “Self-serve” member services such as price estimators intend to empower users, but can lead to apathy or frustration if members don’t understand how to act on the information
• Virtual-first benefits aim to facilitate convenient access to care, but can create disconnected care or trust issues and exacerbate healthcare disparities
  

Omni-Channel Communication

Payers are rolling out more personalized, accessible platforms to members, with a focus on better communication. This has led to a proliferation of channels with members now receiving texts, calls, mailers, and emails, as well as accessing apps and websites. The multitude of communications may offer overlapping or conflicting information. In fact, the tactic doesn’t address well-documented problems with member engagement: 51% of members are dissatisfied telephonic engagement and 32% were not happy when interacting with their insurer’s website. And this is just engagement with health insurers, a single stakeholder in the vast healthcare ecosystem. Further frustration and confusion abound when you factor in communication from providers and pharmacy.

Building out novel platforms without improving core traditional channels may also leave certain members behind. Elderly or lower-socioeconomic status members may not have access to smartphone-enabled apps or texts; if these channels become a payer’s “gold-standard” for member engagement, they may end up underserving the most vulnerable.

To create truly member-focused communication, payers can start by fully understanding the member’s condition and journey, selecting priority channels, and working towards channel integration. The final step is especially important, as over 50% of insurers report that they struggle to track existing member engagement channels. After first building these foundational capabilities, payers can then begin to tailor and personalize member outreach.

At the end of the day, it’s not simply about building as many access points as possible and letting the member choose their favorite. Choice for choice’s sake creates a “paradox of choice” leading to confusion and disengagement. Instead, payers should communicate in the cleanest, most direct, and consumer-preferred way, and guide the member to the best channel for them to access care given the context of their conditions and needs. Segmentation across wants and needs – and clinical demands – is not easy, but it’s necessary to be an effective consumer-centric organization.

“Self-Serve” Member Services

The shift to payers putting healthcare choices in the hands of their members is both popular and commendable; however, as with any trend, it can be taken too far. Certain “self-serve” models provide members with information ranging from provider directories to price estimator tools and rely on them to make their own care decisions. This model may work for a small proportion of more health-literate adults but could leave others overwhelmed and under-supported. Today, 70% of Americans think that the healthcare system is difficult to navigate, with ~40% feeling that they don’t understand their care. The movement to increase transparency could add to that confusion. Price estimator tools, for instance, often vary between payers and providers. Government regulators, accreditation organizations, medical societies, and insurers have different quality metrics. There’s no uniformity in how that data gets presented or if it gets married to price transparency information. Relying on consumers to sort through this jumble of data to make unassisted choices may exacerbate member uncertainty, isolation, and frustration.

In fact, many populations rely on their health insurers when selecting and getting access to care. Medicare members cite payers and brokers as an invaluable source of information when selecting a plan. Once members join a plan, personal relationships with care managers demonstrably improve their outcomes. This is especially true for Medicaid and dual-eligible members as they face unique SDOH needs: in a recent University of Michigan Institute for Healthcare Policy and Innovation study, Medicaid community health workers were able significantly improve clinical outcomes and decrease inpatient readmission rates via deep member engagement.

The idea of truly member-owned care navigation is enticing but does not fully consider the intricacies of the healthcare system. Making healthcare choices is so much more complex than buying a new television or searching for the cheapest available flight. When it comes to decisions surrounding care, members are asking for support and payers are well positioned to provide it.

Virtual-First Benefit Design

Related to increasing access to care and empowering end-users, plans have increasingly promoted virtual care over the past years, especially during the pandemic. Certain payers have even rolled out plans where a member’s primary source of care is virtual. This can be an effective and accessible care delivery option for some, including rural populations or the relatively healthy and tech-literate. For other populations, this is not an effective or preferred approach: Oliver Wyman’s Consumer Health Survey revealed that over half of members would rather see their physician in-person. And although telehealth still accounts for 8% of outpatient visits, there’s been a considerable drop off in utilization since the height of the pandemic.

All-in endorsement of virtual care may also ignore member access issues. Most members are able to receive telephonic care but there is greater disparity when it comes to video access, a more personal and effective virtual platform. Highest utilizers of video telehealth tend to be high earners and those who are young and/or White; meanwhile, those without a high school diploma, older adults, and non-White populations report significantly lower use.

Ultimately, virtual care is an important element of care but should not be the only platform. Payers can play a powerful role in coordinating care across virtual and in-person care by first considering member SDOH needs and ability to leverage various technologies, acknowledging that not all care can or should be delivered virtually. Payers can then carefully select vendors / in-network providers based on those needs and coordinate member care, including enabling them to move seamlessly and appropriately between virtual and in-person visits.

Matching Intentions With Outcomes

It sounds simple, member-focused design should be based on member capabilities, needs, and care goals. But most organizations fall short when it comes to execution. Rather than chase the latest-and-greatest trend, payers should take a step back and evaluate the true impact of well-intentioned actions using the following tenets:

• Consider the holistic member journey by population segment, and how new approaches could enhance or disrupt experience
• Ensure new approaches factor in member SDOH needs beyond health status (i.e., design based on the most vulnerable, at-risk populations)
• Empower members while providing the support and guidance they need to make informed decisions

Payers have an extensive amount of data at their fingertips and should tap into that to more seamless and thoughtful interactions. With these core capabilities in place and thoughtful adoption of evolving trends, payers can truly shift to member-centered engagement and care.