Rama Rao, Florent Moise and Sean Newcomb co-authored this blog post with Harbinder Raina. This is the second post in a series on improving the member experience.
Member Outreach: A Win-Win Innovation?
As part of our customer experience study, aimed at understanding the drivers of customer experience, we interviewed several health plan executives, and it was very clear from those interactions that plans see member outreach programs as a win-win. Active member outreach helps in improving care management, controlling cost and potentially leading to positive member experience. Aetna, for example, reported that its case management outreach program could save $2 to $9 per member per month. If these estimates remain accurate, Aetna, with its 22.1 million medical members, stands to shave up to $210 million a year from its budget.
Through these outreach programs, plans target support efforts to members based on their specific needs. The member outreach could be related to member education, helping members navigate the system or care management. According to the health plan executives, these programs are in great demand from large employers. But do these programs really benefit members the way their plans believe they do?
The Voice of the Patient
For some members, there is no doubt that outreach programs are a welcome benefit. One of the members we surveyed shared with us, for example, that the “RN from the health plan contacted me post-hospitalization for a colonoscopy to answer clinical questions and assured me that ‘I am not alone’ and provided a ‘health line number’ to call in case of questions.”
Other members are simply confused about the purpose of the programs. One member we surveyed described this experience: “I got a call asking about asthma medications. I did not expect a call and it was awkward; should have let me know beforehand about the call and should be done more frequently to build trust.”
What’s the Disconnect?
It should be no surprise that the “missing link” here is program design. A well designed and executed outreach not only provides a positive experience to the member but also helps in building trust between members and their health plans. At the same time, an outreach executed in an uncoordinated way is annoying and creates frustration. Unfortunately, we heard more stories of uncoordinated outreach than well-orchestrated engagements. One of the members summed it up well by saying, “Random call enquiring about health and medications from plan was awkward. … Tell me why and tell me when beforehand.”
This disconnect isn’t intentional. Most health plans have separate teams (care management, customer support, pre-authorization approval, etc.) that manage various outreach programs independently. Lack of coordination among programs emerges as an unintended side effect, which at best frustrates and at worst erodes trust with members who are looking for (but not always getting) continuity and transparency in their care.
Plans Need an Orchestrated Approach to Outreach
To address the disconnect and allow plans and members to reap the benefits of outreach programs, plans need to implement an orchestrated engagement approach, which can be achieved by delivering the right message at the right time through the right channel, and in the right sequence.
To create this orchestrated outreach, plans will have to shift from an initiative-based approach, where health plan teams work in silos (with no central member database) to a member-journey-based approach with journeys designed for each member segment.
A Simple Formula for Making It Work
An orchestrated outreach approach has three key tenets, the combination of which shift the outreach program from a plan-focused initiative to a member-focused benefit, as follows:
- How it works: An informed system or orchestration engine determines the right channel, content and frequency that works for the member.
- Example of patient benefit: For a patient who goes through the pre-authorization process every quarter, the orchestration engine will send a personalized reminder to start the pre-authorization process well before the prescription refill date. After learning enough from the pre-authorization calls, the orchestration engine might provide the pre-authorization automatically to Mr. Brown and inform him accordingly.
- How it works: A central, intelligent system synchronizes all touch points with the member, at each step of the member journey.
- Example of patient benefit: For a patient who has been “flagged” as non-compliant because of pre-authorization delays, the orchestration engine will recognize the reason the patient hasn’t filled a prescription and will stop sending messages regarding adherence.
- How it works: Advanced algorithms provide real-time decision-making ability to adapt to the events in the member journey and recommend the next best action.
- Example of patient benefit: In the event of formulary changes, the system will alert affected patients or their healthcare providers about the update on coverage. The engine will collect inputs from several sources, including EMR at each patient’s HCP, and will recommend an alternate medicine with similar efficacy and safety results.
We have witnessed significant improvement in customer experience achieved by applying an orchestrated outreach approach in the sales and marketing functions. We believe that the same concept can be applied in health insurance for customer engagements along the entire customer journey. And by incorporating personalization, synchronization and adaptability, one step at a time, plans can realize the returns at every step of the way.
In an upcoming blog post, we’ll explore more ideas, coming out of our research, to improve the health plan member experience.