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5 ways to be member-centric


These approaches exemplify the path health plans need to take for effective consumer centricity.

In response to increasingly more educated and knowledgeable consumers, health plans have looked for ways to better engage and connect with members. They strive to provide not just services, but also an overall experience that can become a more integral part of members’ daily decisions that will ultimately affect outcomes.

Cigna, for example, created a comprehensive healthcare experience several years ago, according to Matt Manders, president of regional and operations.

“We’ve banished the term ‘member’ from our vocabulary,” Manders says. “Our thinking is that people don’t consider themselves to be members of a health plan-they think of themselves as individuals, customers, consumers of health services. The sooner we begin to refer to people in those terms, the more our mindset is to treat people as they want to be treated.”

Aetna has taken a similar approach, according to spokesperson Ethan Slavin. 

“Over the past few years, Aetna has had a focus on reaching out directly to consumers to help them become more engaged in their healthcare and empower them to live healthier lives,” he says. 

Refreshing its brand with a new logo back in January 2012 helped Aetna highlight its evolution from an insurance carrier to a health solutions company conveying “much more of a lighter feel and consumer focus,” according to Slavin. In the summer of 2013, it also launched the “what’s your healthy?” campaign and interactive website.

These approaches exemplify the path health plans need to take for effective consumer centricity, says John E. Schneider, PhD, CEO, Avalon Health Economics, a Morristown, N.J.-based healthcare consultancy. 

“First and foremost, plans need to convey to enrollees that they are on the side of the consumer-on their team,” he says. “This sentiment must be expressed consistently through all of the main points of contact between plans and enrollees.”  

The health plan should also play a role in helping members manage logistics, Schneider adds. “This approach has two advantages: It increases enrollee satisfaction and it increases the opportunities for the plan to improve the outcome of a case,” he says.

Members with increasing access to data from multiple sources have demanded a new experience “focused on ease of access to the healthcare system; billing and payment transparency; effectiveness; and actionable information from their health plans and providers to improve their health,” according to Joseph Mack, MPA, president of Joseph Mack & Associates, a business healthcare advisory in Dana Point, Calif.

How can the industry change from provider- or payer-centered processes to member-centered processes?

More than likely, the member-centered processes would have to be in addition to the provider and payer processes, according to L. William Katz of Katz & Associates, a healthcare consultancy in Gilbert, Ariz. 

“It is difficult to imagine how this would be possible given the limitations on administrative costs in the Affordable Care Act,” he says.

Consumer-centric health plans strive to meet the following benchmarks:


NEXT: 5 benchmarks >>


1/ Define quality in terms of convenience

In the digital world in which we now live, consumers are defining quality in terms of convenience, according to Aetna’s Slavin.

“It’s important to meet members where they are with resources and information that help simplify and improve their healthcare experience,” he says. “We strive to have essential information available at someone’s fingertips at the point where it matters most.”

In addition to providing valuable information at the right time, Aetna hopes that the tools it offers are convenient and help consumers become more fully engaged in their own healthcare. For example, the plan provides tools such as the Member Payment Estimator, a transparent cost estimator that can help people compare the varying range of prices for health services, technologies such as the iTriage app, a symptom checker that helps consumers make better healthcare decisions, and its CarePass platform, which offers access to health and wellness mobile apps, Slavin says.

These tools help consumers and providers make better decisions, which can lead to improvements in outcomes and costs, he adds. 

2/ Resolve logistical nightmares

It is only natural that members will complain if there is a “drop” in the perceived service level. 

“As we are seeing with the public exchanges, health plan members need easy access to the plan and their provider network. Those who have trouble finding doctors, getting their ID cards, or who need help with claims, referrals, or determination, need these services and will complain if they are not available,” says James Smith, senior vice president of The Camden Group, a healthcare consulting firm headquartered in Los Angeles, Calif.

The good news is with feedback, health plans can and are improving these utility functions to provide better services over time. Schneider urges health plans to consider the small things. 

 “By paying closer attention to the small services-finding a doctor, finding a radiology center, figuring out how to get a colonoscopy-plans may very well be preventing more costly outlays down the road. Moreover, this approach has the potential to make enrollees feel like the plan is indeed on their side-their partner in helping navigate the often confusing and daunting healthcare system.”




3/ Optimize communications

The healthcare system is viewed by most as a confusing and intimidating patchwork of providers and payers, with the consumer often caught in the middle of disputes between payers and providers, according to Schneider.

The use of jargon generally exacerbates the feelings of alienation that enrollees can sometimes feel. “Plans should look for ‘softer’ ways to communicate with enrollees,” he says. “Describe the concept before tagging it with its official name, and do so repeatedly in all forms of communications-telephone, mail and web. Too often there is a lack of consistency in the content plans deliver to enrollees.” 

Aetna, for example, has had a wide range of initiatives over the past few years to use more plain language when interacting with members. Aetna’s work in this area has been recognized several times over the past three years by the Center for Plain Language. Aetna’s efforts to help people better understand their health benefits include writing materials at a fifth-grade reading level and sharing self-help tools.

The classic example of a confusing, jargon-laced document is the Explanation of Benefits (EOB).

“We found that most people think that coinsurance is ‘insurance for me and my spouse,’ that the provider is the insurance company, and EOB is the ‘This is not a bill’ letter,” Cigna’s Manders says. “We’ve taken these learnings and socialized them throughout the enterprise so that we can better connect with our customers by using simple, clear and common-sense language.”

Now, its EOB resembles a supermarket receipt: Treatment price, plan discount, how much the plan paid, applied health savings account dollars and how much, if anything, the consumer owes.  

“In doing so, service call questions about the EOBs have dropped by one-third,” Manders says. 



4/ Be a facilitator of care 

Cigna has transitioned from “gatekeeper” to facilitator for the individual.

“For example, we all know about the potential health risks and costs associated with excessive radiology imaging, and so our contracted physicians will direct their patients to our consulting services to help them find the best local option for those services,” Manders says.

In most cases, if a physician recommends a particular test or treatment, the patient will believe that the test or treatment is critical to their well-being, according to Schneider.  

“This is less of a problem when dealing with patients who have done their homework-a well-prepared patient may very well challenge a physician as to whether a test or procedure is necessary,” he says. “However, most patients lack this level of preparation, or simply lack the nerve to challenge the authority of a doctor.”

Schneider says plans should explain when the test or procedure the physician ordered is inconsistent with guidelines. The statement could be generated using the same database query used to determine prior authorization, he says.

It is important that health plans respond quickly with treatment recommendations based upon the latest medical scientific knowledge. There still can be a disagreement and in those cases a progressive review by care managers or committees of physicians become part of the process. But the ultimate goal would be real-time response at the point of care.

This is where health plans can perhaps learn from the provider community. 

“Most clinical areas of medicine have developed clinical practice guidelines [CPGs] in their respective disease areas,” Schneider says. “CPGs also have spread to acute care settings, offering real-time guidance on diagnosis and treatment. Plans can do the same. Leveraging the wealth of data that plans now have on their enrollees, it should be possible to quickly ‘score’ each request for authorization against the backdrop of the patient profile and clinically recommended diagnoses and treatments based on CPGs.”

Outright denials for treatment are rare-occurring less than one-half of 1% of the time, according to Manders. 

In general, Slavin says that Aetna has prompt turnaround times for preauthorizations and uses a peer-to-peer review when needed. The plan posts all of its clinical policy bulletins on its public website. 

“We want members and doctors to know what to expect,” Slavin says.

As performance-based and narrow networks begin to dominate the public and private exchange markets, authorization and referral mechanisms must become even more member responsive.

5/ Enhance provider relationships

Plans have a goldmine of claims data and should empower providers to produce quantifiably better outcomes. 

“The information must provide physicians with a better understanding of their patients’ diseases and how their treatments positively or negatively affect results; how it can mitigate their malpractice risks; and, how it will increase practice profitability, through efficiencies that are qualitative and which are the most cost-effective,” Mack says. 

At the same time, it’s important to be proactive in counseling members about choice of providers as well as treatments, according to Katz. Narrow networks might scale down choices to only the best or most efficient, but he believes network optimization should reach beyond just the physician and hospital participants.


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