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Collaboration, Access to Care, and Member Experience Essential to 2022 Health Plan Success


A look inside six trends that will shape and influence care, planning and performance over the next year for health plans.

Value, quality, and experience topped health plan members’ wish lists in 2021, amid a still-uncertain care environment. In 2022, nearly two years into the pandemic, these priorities remain, but but the pressure has intensified.

Health plans will be expected to deliver on promises, while facing monumental challenges—a turbulent economy, a higher threshold for achieving an “exceptional” Star Rating status, and hospitalization surges with the omicron variant. Additionally, the CMS increased its cut points for achieving the 4.0-star benchmark, while eliminating the pandemic-based grace period, which included modifications due to COVID-19, that boosted many health plans’ Star Ratings in calendar year 2021.

Adam Higman

Adam Higman

Health plans will need to consider all of this, while the spirit of consumer choice looms large; members won’t think twice about disenrolling in health plans that don’t provide a great experience, particularly in more competitive markets.

So what’s the game plan, given these realities?

Below are six trends that shape the coming year and what they mean to health plans and their members:

Trend #1: Addressing barriers to care will shape member experience for years to come.

More than 18 months since CMS doubled the weight of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient access and experience measures, health plans are at a critical juncture. They either do their part to elevate the standard of care and service, or they fall behind their peers. Getting ahead in 2022 will make all the difference. Addressing barriers to members receiving the care they need is key. For instance, are there geographical or language barriers that make it harder for non-English-speaking plan members to find a specialist? Could improvements in technology access (virtual care, for example, make a difference)?

Isolating the poorest-performing areas — medication convenience or customer service, for example — and then addressing root causes can help health plans determine the best options for enhanced benefits or programs. Using member surveys ahead of CAHPS can help to identify, say, how patients in a particular community are affected by barriers.

Trend #2: More comprehensive analytics functions will inform care decisions.

The use of analytics is on the rise. According to a May 2021 report, the analytic platforms software market grew by 4.4% to $25.5 billion in 2020. These figures illuminate organizations’ hunger for information, especially in healthcare. As such, 2022 will usher in a stronger demand for more advanced predictive as well as descriptive analytics platforms, embedded with advanced machine learning technologies. Through these applications health plans can not only identify root causes (e.g., the “why” driving a particular CAHPS response), but also predict future behaviors (e.g., the likelihood that Medicare Advantage patients in a particular region will rate their providers highly, based on multiple factors).

Leveraging multiple analytics capabilities could do wonders for health plans that hope to reshape quality of care, plan design, and future initiatives. These analytics also allow plans to better evaluate if the “juice is worth the squeeze” by connecting improvement initiatives directly to key performance indicators tied to CAHPS outcomes.

Trend #3: Focusing on least engaged members will improve performance.

An effective strategy to help maintain high Star Ratings (or increase lower scores) is to focus on less-engaged members. These are the individuals who are less likely to understand their benefits, do not call customer services for information and are more likely to disenroll after one year in a health plan. They are the members who tend rate plans poorly, according to Press Ganey/SPH Analytics CAHPS Book of Business (BoB) 2021 data.

For 2022, health plans should expand efforts to identify barriers to engaging these individuals (e.g., prescription drug logistics, network gaps, out- of-pocket affordability, etc.) and launch initiatives that will enhance their care opportunities and keep them engaged. Engaging the disengaged is, obviously, easier said than done. But analytics that enables cohort segmentation can help health plans identify specific populations for targeted messages that will drive desired member behaviors and outcomes.

Trend #4: Supporting diversity, equity, and inclusion (DEI) will mean taking action.

Given the growing need for affordable, accessible, and equitable healthcare for all Americans, organizations are facing growing pressure to improve diversity, equity, and inclusivity, or DEI. In 2022, the onus will be on tailoring care and service to the neediest individuals who are typically underserved: economically challenged racial and ethnic minorities, or individuals with disabilities, such as for dually eligible (Medicare and Medicaid) seniors who live with multiple chronic conditions, as well as cultural/language barriers. These are the members who, by and large, don’t have their needs addressed and may not trust the U.S. health system. Winning them over, for example, with programs that speak to their direct needs (e.g., rewards programs that align with medication adherence) could be the difference between a 4.5-Star Rating that earns bonus payouts and one that doesn’t.

Crafting member-improvement initiatives that target all patients — not just the most affluent — will help health plans impact scores and ratings while changing lives. Improving in this area for many plans starts first with getting better data on components of DEI to allow plans to better segment populations by their specific needs. Improving the accuracy of data about race, ethnicity, sexual orientation, and language often means multiple touchpoints through surveys, digital and customer service interactions with a sensitivity to when and why the questions are being asked.

Trend #5: Communications will shape member perception.

What you say and how you say it is always important. For health plans and providers, so is the way a message is delivered. While younger, millennial and Gen Z members may gravitate toward text-based reminders (e.g., flu shot reminders), Gen X and Boomer members may prefer email or phone calls. Understanding preferences can help plans improve compliance, outcomes, and overall experience , including high ratings for CAHPS experience-based metrics such as “Doctor listened carefully to enrollee” and “Customer service gave necessary information/help.” With pressure to elevate CAHPS scores and experience in 2022 higher than it was just one year ago, health plans need to prioritize communication strategies and ensure they’re delivering information in a personalized, streamlined way.

Developing profiles around member engagement and responsiveness to campaigns is critical to effective utilization of plan resources. Disengaged members who are unresponsive via traditional modes like mail or email may require personalized customer service outreach via phone or even an in-person visit. Members with socioeconomic headwinds may have inconsistent phone numbers or home addresses, requiring partnerships with providers to engage them with critical messages in care. Even the most engaged members may require “white glove service” for initial enrollment in programs like mail order, pharmacy or telehealth. The more resource-intensive outreach modes should be targeted to those members who are least likely to engage via other methods and should prioritize members who will be most impacted in terms of health outcomes and member experience.

Trend #6: New economic realities will motivate closer payer-provider alignment.

Payer-provider collaboration is a core principle of value-based care, exemplified in multiple federal programs that are increasingly tied to profitability: High-performing plans are moving toward risk-based arrangements around member experience performance and the provider measures of experience (e.g. access, physician communication, care coordination).

Incentivizing provider partner performance starts first with consistent communication from provider-facing teams, accurate measurement of that provider experience (through tactics like post-visit surveys or sharing of data), and shared work to improve that experience. The highest performing plans have clear alignment, best practices and tools for their provider partners. This typically requires a shift in focus and upskilling of provider-facing teams to become better versed in patient experience improvement, which requires a different approach than traditional tactics around HEDIS improvement and care gap closures.

Changing times, challenges, and opportunities

These trends, which are expected to impact all health plans in 2022 — from regional payers to national organizations — highlight new opportunities to raise the bar on care, service and quality. Those that take action early rather than later and embrace analytics in new ways, fine-tune member communication, and seek out solutions to access challenges, will be poised for greater success.

Adam Higman, DHA, FACHE, is a partner, strategic consulting, for Press Ganey.

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