HealthFebruary 02, 2024

Addressing shifting member expectations: Five key challenges

Payers and health plans need to meet shifting consumer expectations. By addressing key challenges, they can move towards a more personalized and improved member experience.

As healthcare is rapidly decentralizing, health consumers are in the center of it. For example, 58% of Americans are likely to seek non-emergency care at a pharmacy instead of going to their primary care physician, according to a recent Wolters Kluwer sponsored survey.

Consumers are dictating new trends, which requires payers to adjust their operations to facilitate these new health experience expectations. As payers adapt they’ll need to address some key challenges along the way to build member trust and ensure long-term growth.

1. New delivery mechanisms for health information

The COVID-19 pandemic changed how and where health consumers receive care and health information. Accelerations in telehealth and digital platforms and new preferences in health education have led to increased expectations of personalized and convenient care.

To meet changing expectations, payers will need to find solutions that can equip members with personalized health education content with flexible delivery mechanisms that supports where and how members prefer to access information.

2. Continued rising health costs

Healthcare costs continue to grow through more complex medical procedures and advanced drugs, and payers are feeling the impact. In 2021, the US spent $4.3 trillion on healthcare with private insurance companies paying 28.5% of the total. According to the Centers for Medicare & Medicaid Services (CMS), national health expenditure is projected to grow an average of 5.4% through 2031.

The shift towards value-based care is focused on better outcomes and focusing on the whole patient – while that can help curb costs, payers will need to find ways to engage their members in their own health journey to improve adherence and reduce unnecessary spending.

3. Increasing focus on social determinants

With the focus on value-based care and outcomes, more emphasis has been put on seeing the member as their whole self beyond their disease or condition. Payers are increasingly integrating elements of Social Determinants of Health (SDoH) into their plans, such as food insecurity, mental healthcare, and transportation to air-conditioned locations during heatwaves. They are also donating to food pantries and non-profits in areas where social determinants can impact health factors.

But the challenge remains – members still want to be seen for their whole selves and not just a diagnosis. This will take continued work in benefits and plan design as well as in aligning with providers to build long-term trust and engagement.

4. Addressing payer-provider friction

Aligning payers and providers with coverage and care plans continues to be a challenge. Without alignment, members can feel the impact the most through inconsistent care decisions and health information, complex plan coverage, and extra costs. 

Reducing this friction can benefit everyone - one study even advocates for the role that payer-provider partnerships can have in addressing SDoH through integrated delivery systems. Having access to the right clinical evidence – ideally that which clinicians themselves trust and use – can be instrumental in aligning coverage and plan decisions with providers to reduce friction and to improve member experiences.

5. Pressure to meet quality metrics

As payers strategize to meet value-based care objectives like health quality and outcomes, there is additional pressure to meet HEDIS and STARs metrics. Staying updated on changing measures can be challenging, and payers will need to find new and innovative ways to equip members with the right health information to meet these standards and improve care. Additionally, by addressing the above challenges, the member experience can improve, impacting quality metrics.

Creating a more personalized member experience

While facing many challenges in this shifting landscape, health plan companies have opportunities to make inroads towards their business goals and improving ROI. By focusing on members, equipping payer teams with trusted, authoritative tools for decision making, and providing a supportive, personalized experience with health content to help members take control of their journey, health plan companies can lay the foundations for scalable success.

Learn how personalized member experiences and aligned health information can be the key to success for payers. 

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