How can we build better experiences for members and patients, and ultimately improve plan performance?
Many health plan CTOs and operational leaders grapple with this question as consumer expectations rise and infrastructures must become increasingly agile. However, common complexities often hinder health plans from enhancing their operations in ways that benefit members. Here are the top challenges they face when unifying operations:
Shifting Regulatory Landscape
Health plans are governed by multiple entities and several sets of regulations that guide operations. In recent years, laws such as the REAL Health Providers Act and the No Surprises Act have dramatically changed standards around member transparency. And Medicare health plans continuously navigate the shifting goalposts of Star Ratings. These regulations are not merely procedural; they strategically shape how plans operate and engage with members. Health plans must balance meeting these laws with the constant evolution of market demands and technological advancements.
Member Expectations Shift Across Demographics
Health plans must cater to a wide range of populations, from the young and affluent to the elderly and economically disadvantaged. Each group has distinct needs and expectations, particularly for personalized and effortless healthcare experiences.
Tom Cohen, Executive Vice President at Softheon, shares his experience personalizing communication and operations to specific lines of business during an AHIP-sponsored webinar:
Market Changes and Technology Advancements
Market changes further complicate operations. Updates to the medical loss ratio (MLR), technology advancements, and market expansions all require health plans to manage numerous programs that affect their members and patients. The rapid innovation in data management and large language models (LLMs) means that enterprise data management is also evolving swiftly, impacting every facet of health plan operations. But, the questions around AI regulations have many health plan leaders hesitant to implement across core or member-facing operations.
These common and recurring complexities make it difficult for health plans to even quantify operational success.
“We are operating in a complex environment influenced by diverse member needs and regulatory frameworks which require agile responses from health plans,” shares Tom.
During the webinar, AHIP plans shared how they viewed their current capabilities to execute an experience for their membership and their population:
The majority agrees, we still have a lot of work to do.
Simplifying the Experience Across Multiple Lines of Business
Members often transition between multiple coverage types—from Medicaid to the ACA Marketplace, and eventually to Medicare. Each transition involves significant changes not just in coverage but also in the data that underpins these movements. For health plans, maintaining a consistent and accurate track of these transitions is as challenging as it is vital.
Implementing a Unified Data Model with a Universal Member ID
To address these challenges, many health organizations are shifting from isolated interactions based on lines of business to a more integrated approach. Central to this shift is implementing a “Golden Member ID.” This unified data model ensures that no matter where a member moves within the system, their information remains consistent and accessible.
Ensuring Cohesive Experiences and Performance Alignment
From the backend, the intricacies involved in aligning performance metrics across different plans, such as Medicare KPIs versus ACA targets, highlight the need for a comprehensive data strategy. Health plans often find these metrics siloed within their operations, leading to fragmented efforts that can detract from overall performance goals.
To combat this, health plans are adopting strategies that ensure these metrics are not just aligned but also collaboratively optimized across the organization.
Automating and Personalizing Member Communication for Better Experiences
Effective communication between health plans, providers, and members is crucial. Yet, health plans often find it difficult to align communications due to siloed operations. Assets like care coordination tools and historical claims data are underutilized. To overcome these barriers, health plans must focus on breaking down silos and integrating data across different departments and functions.
A notable example of health plans effectively working with providers is a Medicare plan that designed a model specifically for its highest-risk members. This plan not only identified at-risk individuals but also synchronized their care schedules directly with the providers. By doing so, it ensured that providers were well-prepared for upcoming patient visits, focusing on those most in need of immediate attention. This level of detail in personalization helps manage chronic conditions effectively and reduces potential health risks, showcasing a proactive approach to member care.
Listen to Harlan Edlin, President at Novillus, share the full story of how a Medicare plan was able to combine member and provider data for a personalized approach:
Despite best intentions, communication efforts can sometimes backfire. Harlan also shared a story of how a health plan unintentionally bombarded members with over 300 messages in a year due to a lack of coordination among its digital, marketing, and specific line of business teams. This example highlights the critical need for integrated communication strategies that prevent overlapping and ensure messages are timely, relevant, and coordinated across all channels.
Simplifying the Member Experience: A Call for Fundamental Enhancements
Recent polls with AHIP health plan leaders reveal that guided shopping, care scheduling, and risk management tools are perceived as top areas where operational improvements could most directly impact members:
Harlan points out that the hype of chatbots has died down. “For a moment, chatbots were sort of taking over the world, and now they’ve been completely demoted, and we’re really focusing on what’s most important,” he comments. This shift suggests a broader realignment within health plan strategies, focusing more on substantial and meaningful technological advancements that address core operational needs and member satisfaction.
Health plans are shifting focus from adopting new gadgets and sophisticated technologies to simply enhancing the user experience. “Most people simply want solutions that work,” Tom emphasizes, urging caution in the rush toward new technologies.
Leveraging AI and APIs Strategically
While advanced technologies like AI are valuable for enhancing operational efficiencies and personalizing experiences, their deployment must be thoughtful and measured. Members should feel supported, not overwhelmed by these technologies. Integrating AI and other tools should genuinely enhance the member’s journey without complicating it unnecessarily.
The use of Application Programming Interfaces (APIs) is a fundamental area where many health plans continue to struggle. APIs facilitate smoother data integration across various platforms and systems, enhancing the coherence of the member experience. Without robust data integration, health plans find it challenging to provide seamless and effective interactions. It is crucial that these technologies are used to streamline processes rather than add to their complexity.
Building on Strong Foundations
The cornerstone of any effective health plan operation is robust and accurate data. The capability to utilize standard API frameworks and efficiently ingest data from ecosystem partners is essential. Poor data management can significantly hinder a health plan’s ability to deliver positive member experiences. As Tom points out, “You have to get the basics right, and data is at the foundation of that.”
“I really do think that having those core building blocks, and maintaining the principle of simplicity, is where you’ll see market improvement,” Tom concludes. This approach not only boosts member satisfaction but also positions the health plan for better market performance and competitiveness.
To watch the full recording of Tom and Harlan’s discussion, check out Softheon’s YouTube channel.
