What does member experience mean for health payers?

Defining member experience for health payers

The health payer member experience refers to the way in which health plan beneficiaries are able to use and interact with their payers. Similar to the patient experience with clinicians, member experience looks at the satisfaction members have with their health plan interactions as well as ease of use and access to quality healthcare.

Many factors can influence member experience, including breadth of benefits, access to provider information and the ease of accessing a plan representative. Claim denials, prior authorizations and other utilization management strategies might also sway member satisfaction and experience.

Why is a good member experience important?

Like their clinician and provider counterparts, payers need to be aware of healthcare consumerism and the way it has shaped patient or member loyalty. Member loyalty is the very factor that will keep enrollees coming back to a certain health plan, and health plans can only cultivate loyalty by creating a good member experience.

Indeed, a 2024 report from Accenture found that members who switched health plans said their decisions were largely motivated by a poor experience with their payer. In fact, member experience outweighed cost, benefits, network breadth and value for members who swapped health plans.

Right now, customer experience in the health payer landscape is falling short, according to a report from Bain & Company. While other service sectors like banking/finance and retail can boast over 50% net positive perception from consumers, the healthcare payer market only sees 31% net positive perception.

These poor perceptions come as healthcare payers have lower digital maturity levels, the report added, indicating some limited investment in customer experience.

However, the report added that investing in customer experience can pay off in the following areas:

• Higher revenues via new accounts, share of wallet with existing members and increased retention.
• Lower call center costs by investing in AI-powered customer service.
• Reduced medical billing costs.

What drives health plan member satisfaction?

Notably, members want their interactions with their health plans to be frictionless.

According to the Accenture report, this boils down to better access to health plan information. In fact, members who said their payer was very easy to work with were twice as likely to stay with their health plan than those who said it was somewhat easy to work with their payer.

Members who swapped health plans said their poor experience was driven by poor access to plan information, an inability to get their questions answered, poor customer service and poor digital interactions.

Health plans might consider their digital presence and how it impacts the member experience, the Accenture report indicated. Members who said it was easy to find information online were more likely to say their health plan was easy to understand overall.

Bain & Company recommended healthcare payers reimagine their customer experience models first by establishing company-wide goals and shared metrics. Next, they should prioritize the member encounters that will provide the highest ROI, whether that be claims management or member engagement. Payers should also prioritize members' biggest pain points, Bain & Company suggested.

Digital engagement and access tools are going to be essential to improving the member experience as healthcare's digital transformation continues. Members want their interactions with their payers to mirror those with other services sectors.

But right now, health payers aren't delivering on that.

As noted by Bain & Company, health payers are not digitally mature. According to a 2024 J.D. Power survey, a lack of digital engagement is harming nearly every payer on the market. For example, member portals fall short of consumer expectations.

Meanwhile, members reported that it's hard to reach their payers by phone, with around a third needing to call their payers two or more times to ask a question. Even then, 45% of consumers said that their issue remained unsolved.

Bain & Company said every customer service initiative needs to be capped off with an omnichannel engagement investment. This ensures members have multiple channels by which they can access information from their healthcare payers.

It will be key that information remains consistent and clear across channels to avoid confusion for members. Additionally, using a "no wrong door" approach to digital engagement will help members get the information they need regardless of how they interact with their health plan.

Key technologies to support a better member experience can include the following:

• Digital member portals.
• AI-powered chatbots.
• AI for personalized member engagement.
• Digital bill pay solutions.
• Digitized call centers that are supplemented by human call center operators.

Metrics and KPIs for measuring member experience

As health plans work to improve the member experience, they must understand the key performance indicators (KPIs) and measures that assess member experience.

A handful of measures look at overall member satisfaction levels. These assessments give an overall rating of the health plan:

• Health Effectiveness Data and Information Set (HEDIS).
• Star Ratings.
• Net promoter score or likelihood to recommend.
• Consumer Assessment of Healthcare Providers and Systems (CAHPS).

These metrics can help health payer leaders determine the overall sentiment members have about the health plan.

However, health plans must consider other KPIs used across numerous industries to assess the customer experience.

• First call resolution. The number of inquiries resolved upon first member contact.
• Average speed of answer. How quickly a customer service representative answers calls.
• Claims processing time. How long it takes for claims to be processed correctly.
• Appeals rate. The number of complaints and claims appeals that members submit.
• Retention rate. The number of members who enroll with the same payer the following plan year.

As consumer forces continue to shape the healthcare industry, payers will need to better understand their consumers and what drives a positive experience. Assessing member experience goals and the KPIs necessary to measure them will be essential to building better member loyalty.

Sara Heath has covered news related to patient engagement and health equity since 2015.