Four reasons to transform health plan member experience with data and AI

Four reasons to transform health plan member experience with data and AI

Four reasons to transform health plan member experience with data and AI

Four reasons to transform health plan member experience with data and AI

Start here

Start here

Start here

Start here

Embracing a member-driven engagement strategy.

Embracing a member-driven engagement strategy.

2 min read
01

Conversational AI will be integral for health plans

Conversational AI will be integral for health plans

Conversational AI will be integral for health plans

Conversational AI will be integral for health plans

Not automating call centers could impact your bottom line.

Not automating call centers could impact your bottom line.

3 min read
02

Empowered members can make better decisions

Empowered members can make better decisions

Empowered members can make better decisions

Empowered members can make better decisions

How can you build confidence in your members?

How can you build confidence in your members?

3 min read
03

Activist employers demand better open enrollment experiences

Activist employers demand better open enrollment experiences

Activist employers demand better open enrollment experiences

Activist employers demand better open enrollment experiences

Employer clients (and members) require better benefits onboarding.

Employer clients (and members) require better benefits onboarding.

5 min read
04

Government regulations are encouraging healthcare consumerism

Government regulations are encouraging healthcare consumerism

Government regulations are encouraging healthcare consumerism

Government regulations are encouraging healthcare consumerism

Not meeting CMS transparency regulations can damage the perception of your health plan.

Not meeting CMS transparency regulations can damage the perception of your health plan.

1 min read
05

Explore member engagement solutions

Explore member engagement solutions

Explore member engagement solutions

Explore member engagement solutions

Digitally transform your member engagement strategy with the help of IBM Watson Health.

Digitally transform your member engagement strategy with the help of IBM Watson Health.

1 min read
06

Four reasons to transform health plan member experience with data and AI

01

2 min read

Embracing a member-driven engagement strategy


We live in a new world where consumers are in the driver’s seat. People can order almost anything they want any time of day. And these same members rely on internet reviews, word of mouth and mobile app experiences to help them make their decisions – from food choices, to clothes, to colleges, and now, even health insurance and health care options.

Digital transformation has given health plans the opportunity to reevaluate business strategies and modernize. But what does it really mean for your health plan, especially during COVID-19? It means infrastructure needs a new hybrid approach. You don’t need to “rip and replace” so much as augment what you already have in place to meet today’s demands. With the right engagement strategy, you can meet the demands of your stakeholders – from employer groups to members to the US government.

A man using a laptop
A woman using her smartphone and writing

“The last, best experience that anyone has anywhere becomes the minimum expectation for the experience they want everywhere.”

— Bridget van Kralingen, SVP, IBM Global Markets, 2016

To meet members’ needs, health plans must adapt and embrace advanced digital technology to help stay on the leading edge. In fact, at IBM® Watson Health®, we believe there are opportunity costs of moving too slowly – or even worse – doing nothing in support of member engagement.

We understand health plans are in a unique situation. Member health is extremely personal and to establish trust, you need to provide only the best experience while leading them on their individual health journeys. Given an increase in prevention and treatment trends with telemedicine, members are even more ready to take control.

So, why should your health plan invest in engagement tools that can help impact benefits education, open enrollment and price transparency?

Read on.

02

3 min read

Conversational AI will be integral for health plans


Your health plan has likely seen a higher volume of call center activity since the beginning of COVID-19. Agents and members alike are trying to get fast, satisfactory resolutions. But when members are stressed and confused about basic coverage, it could lead to a very disorienting experience that requires more handholding.

Call centers aren’t only a challenge for health plans. In the similarly heavily-regulated world of consumer finance, overall customer satisfaction scores fall 34 points when on-hold wait times exceed four minutes.¹ While longer wait times in our industry might mean an agent is enrolling a member into a care management program, there’s also a strong possibility several of the calls are routine, basic questions. Regardless of a call’s purpose, we know all too well the importance of a strong Net Promoter Score (NPS) among healthcare payers and need to do all we can to improve experiences.

Application

Your call center associates’ efforts are best spent on solving complex member issues rather than routine questions. Conversational AI – or the concept of using virtual agent interfaces that can understand questions and provide plain language answers – can help serve up answers and help augment staff. Your health plan can seek out options that help in areas such as:

preservice icon Pre-service
medical icon Medical eligibility
verification icon Verification
authorization icon Authorization needs
referral icon Referral information
faqs icon Other basic FAQs

Virtual agents exist in the form of web-based self-service tools that understand queries and serve up personalized answers without bogging down call centers.

Assume your call center has a new associate named Demichael. This type of tool could help him focus his efforts on higher-order calls and divert quick questions to an automated solution, helping him reduce stress and corresponding call volume.

A virtual agent can also lead to faster call handle time because FAQs are addressed online. For members, it empowers them to answer questions whenever they occur – even after business hours.

Implementation doesn’t need to be difficult, either. Such virtual agents are trained to understand health benefits and costs. In addition to generic questions such as business hours, location directions and password resets, tools can understand medical terminology. You can also connect conversational AI systems such as this to benefits systems, member data, provider information and more.

The takeaway

Members prefer – and are accustomed to – instantaneous answers in most aspects of their lives. Faster, more consistent answers through member self-service could lead to stronger NPS, better call handle time, and can potentially help you make better business decisions.

¹ J.D. Power, Direct Banks Earn Higher Customer Satisfaction than Traditional Retail Banks, but Face Call Center Challenges, 2 April 2020

03

3 min read

Empowered members can make better decisions


Learning should be a lifelong process. For most, we learn something new daily – recipes, directions, names – whatever it may be, change and learning are two of the only constants in life. Staying ahead of the curve by learning about products and services, and being informed, are what keeps consumers in the driver’s seat.

And in today’s healthcare environment, members who understand their benefits, coverage, and other crucial aspects of their health plan are important to your success.²

It begs the question, how confident are you in informing your members about their coverage? With the advent of portals, apps and other tools we still believe there is some room for improvement.

Application

There are scalable ways to provide more positive experiences for your members in near real time, all while helping them better understand their benefits choices. For instance, let’s assume your health plan has a member named Rita who calls regularly to confirm her coverage. A virtual agent, trained to understand health benefits, can help provide a means for Rita to interact digitally in a natural language query to complete transactional tasks, such as checking coverage details, provider networks or deductible balances. Rita can get accurate answers in minutes – freeing up a call center associate to address more complex needs.

A doctor

Information must be presented to members and other stakeholders in real time in a format that both informs and encourages real-time decision making and behavior change.

Gartner frames a similar situation where technology could have a strong impact:
“Chronically ill individuals require continuous intelligence and analysis of multiple health indicators, events and actions from an expanding array of technologies in, on and around the body.... Information must be presented to members and other stakeholders in real time in a format that both informs and encourages real-time decision making and behavior change.”³

The takeaway

What could be the result of investing in tools that help members with their benefits? In short, you could help alleviate the administrative call center burden and enable more interactive and personalized member support. But it can also create insightful value to your health plan’s integration specialists and business analysts – where conversation data and other chat transcripts inform future investments.

² Accenture, The Hidden Cost of Healthcare System Complexity, Sapna Rao, 2018 (PDF, 516 KB)

³ Gartner, The Evolution of Healthcare Consumer Engagement Hub Architecture, Mark Gilbert, 25 February 2020 (PDF, 218 KB)

04

5 min read

Activist employers demand better open enrollment experiences


Times have changed. Consumers can get what they want, when they want it, however they want it – and will be sure to mention their experience whether positive or negative. In fact, many of us have likely made restaurant selections based on what we heard through our favorite medium of choice: print ads, email or websites just to name a few. Consumer selection can even apply to open enrollment.

Employer and member perspectives

Activist employers — the benefits leaders who want to drive change in the way US healthcare is delivered — are willing to switch plan vendors if they aren’t satisfied. This presents an opportunity for health plans who also know the importance of boosting member engagement and satisfaction.

Whether it’s the annual open enrollment period or a qualifying life event, many members are concerned about finding their best-fit plan. Deciphering complex literature and not being able to forecast future health costs can lead to over- or under-insuring. Many opt to just keep the plan year over year regardless of financial consequences.

Looking at this challenge through the lens of COVID-19, it could be especially prevalent among members who deferred care. The physical and financial costs of delaying necessary or elective surgeries could drastically impact plan selection. Prompting members to think about their upcoming needs could help lead them to selecting a more appropriate plan.

a woman called Juanita
a man called Jeff
Application

While employer clients try their best to educate their employees about benefits enrollment, it’s frequently not scalable – staff-led webinars, flyers and individual email correspondence. And what’s more: Everyone has their own preference.

In one innovative example, Juanita, the head of benefits for a self-insured employer, could work with her health plan to deploy virtual agents for her population. This application uses recommendation engine logic to improve enrollment and potentially improve satisfaction scores. Let’s say one of Juanita’s company’s employees, Jeff, is seeking to switch health plans during open enrollment. Jeff could use a virtual agent that allows him the ability select his best-fit plan based on historical claims data and projected needs.

But some of Jeff’s colleagues might not feel comfortable enough to use a virtual agent. That is why Juanita can use data to learn about her employees’ media preferences and send them enrollment material built for their needs. Whether it’s a detailed health benefits statements sent by US mail, a summary via email, or tools on a self-serve website, she is aware that we all learn differently.

small group using laptopsStart small on your own team

While the idea of increasing member engagement is reason enough to explore new benefits enrollment processes, consider first trying this approach within your own health plan (as an employer). Test, learn and observe how your employees react to customized benefits communications – are they still selecting a default plan or are they taking the time to find their best-fit plan?

A successful pilot within your own organization can serve as an opportunity to sell in data and AI-driven benefits communications as a channel partner to your employer clients. Altogether, this could better demonstrate your value to employers, boost member engagement and help secure incremental business.

People on sofaPayer and provider collaboration

That’s not all. Let’s zoom out and look at the full picture. Investing in a member solution could also benefit the relationship between payers and providers. According to Gartner, health systems of all types can benefit by improving their ability to engage members and care teams during an episode of care.³ Effective engagement within an episode of care improves a health system’s ability to minimize patient leakage and lowers quality risks during care transitions within the episode. Patients also report substantially higher satisfaction scores when their journey through a care episode is coordinated among all parties. In other words, when patient data is securely shared with health plans, it can help improve overall member experience when it comes time to enroll.

The takeaway

The result? Engaged employer clients – and members – who feel educated, empowered and see consistency, can choose to stay with your health plan and not take their business elsewhere.

³ Gartner, The Evolution of Healthcare Consumer Engagement Hub Architecture, Mark Gilbert, 25 February 2020 (PDF, 221 KB)

05

1 min read

Government regulations are encouraging healthcare consumerism


Interoperability is its own discussion, but there’s a strong member engagement angle here, too. The Centers for Medicare & Medicaid Services (CMS) issued rules pursuant to the Executive Order on Improving Price and Quality Transparency in American Healthcare to help empower members and increase competition for shoppable services.⁴ This new rule will require health plans to disclose on a public website their negotiated rates for in-network providers and allowed amounts paid for out-of-network providers.

In short, these policies seek to arm members with the essential information they need to be able to make informed decisions.

According to Gartner, a healthcare consumer engagement hub – a solution similar to the proposed rule – has the following hallmarks³:

focus icon Focus on the long-term
objectives of bending the
cost curve
health icon Increasing the health of
the population
increasing icon Increasing the quality of life
of the population
improving icon Improving the experience
of consumers
Application

This regulation could help your members make more strategic decisions. Let’s think about the use case of a man, Stanley, on your health plan considering a knee replacement. Using a price transparency tool connected to his plan, he could do the following:

A man called Stanley
  • Shop providers for the best price
  • View estimated costs
  • See his total accumulation period
  • Make an informed decision about whether to proceed

Stanley’s medical decision would be based on both estimated pricing and clinical inputs – not minor factors such as location or availability.

Not meeting these regulations per the CMS guidelines could potentially chip away at your operating costs through costly fines and possibly expensive, fast-tracked IT transformation. But beyond the costs themselves, not meeting the regulations could lead to negative perceptions around your health plan in the media or even among employers. Keeping operating expenses manageable while still paying for quality care is a balance you could potentially address by using member-driven cost transparency tools.

The takeaway

While making your health plan’s rates public to follow price transparency guidelines will be required by law, there are better ways to communicate them than uploading a PDF. Implementing a customizable tool that is easy for members to calculate procedure estimates shows you care about experience and empowerment.

³ Gartner, The Evolution of Healthcare Consumer Engagement Hub Architecture, Mark Gilbert, 25 February 2020 (PDF, 221 KB)

⁴ CMS, Trump Administration Announces Historic Price Transparency Requirements to Increase Competition and Lower Healthcare Costs for All Americans, 15 November 2019

06

1 min read

Explore member engagement solutions

A woman using a smartphone

Understanding the importance of investing in tools to improve the member experience has multiple potential advantages, with the main ones being cost savings and fostering positive engagement.

In fact, for payers, longitudinally engaging citizens (members) is a critical capability required for improving the health of citizens and lowering the costs of healthcare.³

So, where should you invest first?

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Learn more about our member solutions for Payers

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³ Gartner, The Evolution of Healthcare Consumer Engagement Hub Architecture, Mark Gilbert, 25 February 2020 (PDF, 221 KB)