5 Key Strategies to Transform the Member Experience

By Rajesh Subramaniam, CEO, ResultsCX
LinkedIn: Rajesh Subramaniam
X: @rajeshsonline

Health plans strive to empower and support members during every interaction, yet the unvarnished reality is that most plans fail to strategically optimize their member experience. According to a J.D. Power study, overall member satisfaction with commercial health plans fell in 2023, driven primarily by reduced satisfaction with customer service.

In fact, nearly half of members who reported problems with their insurance in early 2023 were unable to get their issues resolved, according to Kaiser Family Foundation. Even at the most respected plans, members must often make repeated calls to customer service before issues are resolved, fueling unnecessary costs as well as dissatisfaction that can tarnish the plan’s brand and drive valued members to switch to a competitor.

The consequences can be dire: If members cannot get timely, accurate information on their plan’s benefits, they may delay seeking necessary care, which can have a negative effect on health outcomes. Lackluster clinical performance and member satisfaction can also cause a plan’s Star ratings to tumble. With fewer Medicare Advantage members in plans earning four stars or more in 2024 than just two years ago (74% vs. 90%), C-suite executives cannot afford oversights that compromise on their plans’ member experience strategies.

Fortunately, by scrutinizing their strategies for some of the most serious oversights, leaders can help rein in costs, improve outcomes and create a more positive experience for members.

Strategic Oversight No. 1: Neglecting omnichannel support

Today, members expect a seamless, personalized member experience across a plan’s websites, mobile apps and other channels. Health plans that embrace omnichannel member strategies can realize significant improvements in their clinical and financial outcomes.

One Fortune 50 health plan utilized phone, email and text messages to encourage at-risk members with chronic conditions to schedule preventive care appointments. The campaign significantly improved the plan’s reach, doubling the number of appointments scheduled and exceeding the plan’s goal by 45%. This also led to improved cost efficiencies for the plan, with cost per scheduled appointment cut by nearly half.

Strategic Oversight No. 2: Not harmonizing data and platforms

When member data is dispersed across multiple systems, agents are fettered in their ability to resolve member issues quickly and effectively. They may lack critical information on where the member fits in the plan’s member segmentation, or they may not have access to the member’s previous interactions or social factors – such as disability status or caregiver requirements – that can affect the individual’s ability to see a provider.

However, by harmonizing data into a single, cloud-based platform, plans can reduce the inefficiency of redundant conversations and lost opportunities. For example, when a member calls to check if a physician is in network, the agent can review the member’s recent health assessment in real time and inform them about a new wellness program that fits their needs. By closing the loop in this manner, plans can truly harness their data to drive better outcomes.

Strategic Oversight No. 3: Failing to update member experience technology

Personalized, consistent communication is essential to build trust and loyalty among members, and it hinges on having updated technology. With real-time data analytics, health plans can customize each interaction based on the member’s history and preferences. In addition, with effective personalization engines, plans can utilize member data to create tailored interactions and ensure that members feel understood and valued.

Technologies like predictive analytics can also enable plans to identify the root cause of member frustration on calls and suggest resolutions. One health plan aimed to improve its problematic 4% callback rate and invested in agent assist technology to support quicker resolutions, resulting in more satisfied members. The technology improved overall call scores by 11 points and increased the plan’s net promoter score (NPS), which measures the likelihood that members would recommend the plan to someone else, by 12 points.

Strategic Oversight No. 4: Not employing digital technology and outsourcing to provide an effective member experience

Outsourcing member experience management can help plans realize the benefits of combining people-centered technology with empathy-based human interaction. For example, advanced interactive voice response (IVR) systems that use natural language processing (NLP), a type of AI, can understand members’ speech and route calls more efficiently. In addition, by utilizing chatbots and AI-driven virtual assistants that can answer member questions and guide them to the appropriate resources, plans can redeploy human agents to address more complex issues.

A team from Stanford and MIT found that AI-assisted scripts can improve productivity of customer service agents by 35%. Beyond empowering agents, AI tools can also elevate customer satisfaction (CSAT) scores. Agents for one managed Medicare plan used AI-driven virtual assistants to resolve two common types of inbound calls. After a year, CSAT increased 55%.

Strategic Oversight No. 5: Focusing on the wrong metrics

A plan’s key performance indicators (KPIs) should reflect its strategic goals. While average handle time (AHT) is an essential metric, it does not directly correlate to member satisfaction. In fact, prioritizing call time over other metrics can impel agents to end calls before fully resolving a member’s problem.

For this reason, health plans should also prioritize NPS and other member-centric metrics such as:

  • First call resolution (FCR), which measures member issues resolved on the first contact.
  • Transactional net promoter score (tNPS), which measures member satisfaction specific to interactions with the plan.

Focusing on tNPS is a novel approach for payers, but leading plans recognize that this metric can help them advance better strategies to elevate member perceptions of their plan and increase brand loyalty in a competitive environment.

Benefits of strategically investing in the member experience

While addressing these strategic oversights may be outside of the comfort zone for health plan executives, they do not have to embark on this journey alone. Embracing digital technology and working with a trusted partner in member experience management can help plans achieve their mission of delivering affordable, high quality care to members while safeguarding their margins and reputation in a highly competitive market.