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Improving member experience requires transformational, organization-wide change

Across the healthcare industry, it’s becoming more important than ever before to think about the full lifecycle of the patient or member experience beyond a specific interaction or episode of care. As healthcare consumers, they expect—and demand—the highest quality of care and service. And health plans are no exception. Game-changing revisions from the Centers for Medicare & Medicaid Services (CMS) to the star rating system put an increased emphasis on health plans to improve the member experience—or risk losing millions of dollars in quality bonus payments. That's why many health plans are shifting directions to focus on member experience.

4 departments that can impact member experience 

Improving the member experience isn’t a simple task. Many Americans see their health plan only as an approver—or denier—of medical services. It’s difficult to change members’ attitudes toward their health plan, but it’s not impossible. Doing so requires organization-wide transformational change—it isn’t specific to just one department.

1. Call centers.

When members call, do they get their questions answered quickly? Or do they wait on hold, get transferred to different departments, or speak to a rude customer service representative? The call center is often the primary connection a member has to their health plan. So, if the interaction isn’t positive, they may give their plan a lower satisfaction rating. Health plans can use these methods to improve the member experience with the call center.

Provide regular training for call center representatives. Training shouldn’t be limited to new employees. To improve skillsets for call center representatives, especially around empathy and understanding specifics about the health plan, ongoing training is critical.

Invest in intelligent call routing. When a call center agent is unable to answer a member’s question on their own, it can be frustrating for both the agent and the member. Investing in technology that automatically routes members with specific or complex issues to higher-skilled representatives can improve the member’s experience.

Consider live chat support. With digital chat options, members can receive support, get help finding care options, and locate in-network providers. Getting immediate support can boost member satisfaction, especially when they’re not waiting on hold or for a response via email.

2. Utilization management.

In a 2021 survey from the American Medical Association, 42% of physicians revealed that the prior authorization process often causes delays in access to necessary care. These delays can cause anxiety and pile on stress for patients who are waiting for treatment or medical tests. Additionally, if a health plan and a provider don’t have a smooth process for sharing documentation, a claim might be denied—resulting in an unexpected bill for the patient.

One way health plans can improve the member experience through utilization management is to take a close look at the treatments, tests, and medications that require prior authorization and get these down to the bare minimum. Another option is to bundle procedures by diagnosis so patients need to get approval only at the beginning of treatment. Automating and streamlining the process can also help.

3. Sales/brokers.

For people who shop for their own health plans, the process can be tricky. It can be confusing to navigate premiums, deductibles, and costs—let alone choose a plan that fits. The health plan’s sales team or brokers can help members choose the right plan and make sure that their doctor and/or medications are covered. This can help ensure that each member is satisfied with their plan and that their expectations are met.

4. Product development.

How health insurers design their plans can also contribute to the overall member experience. For example, how much does it cost to go to the emergency room or fill a monthly prescription? Data can show what plan attributes or benefits result in higher levels of satisfaction among members. With Medicare, supplemental benefits like dental care, vision care, hearing aids, and gym memberships can also correlate to higher rates of satisfaction.

There are multiple facets to the member experience, and a commitment to making it the best it can be is the responsibility of everyone within a health plan. From the big picture to the tiny details, a health plan should be focused on the individual’s journey and all the points of contact with them. The organizational transformation that makes this possible may not come easily, but it will pay off in the long term.

Press Ganey’s strategic consultants work side by side with health plan leadership to help organizations improve the member experience. Spearheaded by the expertise of SPH Analytics, acquired in 2021 by Press Ganey, we use a proven, data-driven approach to help health plans focus on member acquisition, engagement, and retention. Reach out to an expert on our team for more information.

About the author

Bonnie leads engagements for the Payer solutions team in Strategic Consulting, partnering with health systems and payer organizations to put patients at the center of care. She develops data-driven strategies to help clients build best practices into the initiatives they’re already implementing. Prior to joining Press Ganey, Bonnie was Director of Health System Improvements at Greater Oregon Behavioral Health. She was in charge of the services that guarantee a great experience for members.

Profile Photo of Bonnie Thompson, MSN, MBA, PMP