Setting the Foundation for Member Engagement Across Populations

Member engagement has wide-ranging benefits, from improving health outcomes and controlling costs to ensuring consumer satisfaction, optimizing risk adjustment, and encouraging adherence to treatment plans. Health plans should be built on a strong foundation of member engagement to be successful in today’s competitive markets. Yet, there are cracks in the foundation.

Many health plans struggle to engage members within their healthcare journeys, whether it be choosing a more cost-efficient location for recommended medical services, attending their annual wellness visit, or managing a chronic condition. 

In particular, plans encounter challenges with engaging members of certain populations, such as older adults qualifying for Medicare or highly complex Medicaid populations.

Only 31 Medicare Advantage plans received five stars— the highest CMS Star Rating — in 2024, compared to 57 plans the previous year and 74 in 2022. While some of the reduction is attributable to the end of pandemic-era flexibilities, member satisfaction is waning — a sign that health plans are missing the mark with member engagement strategies.

Trust and communication are major barriers health plans have to overcome to connect with members.

“Almost everyone can relate to experiences with health plans sending them an explanation of benefits (EOB) or a claim filing that ultimately led to them owing dollars that they didn’t really owe. That is an issue of trust,” explains Kristen Gasteazoro, senior vice president of SmartShopper Sales and Client Performance at Zelis.

Healthcare is notoriously complex; more than half of Americans have low health insurance literacy. Many Medicare beneficiaries also avoid switching Medicare Advantage plans due to the confusing nature of Medicare advertising. Yet, research shows Medicare Advantage enrollees have slightly higher healthcare literacy compared to traditional Medicare beneficiaries.

Where health plans lack, providers tend to deliver. A recent study from NRC Health found that trust in local hospitals and health systems has increased, especially after the COVID-19 pandemic. However, growing trust in providers does not necessarily lead to cost savings or higher quality for members.

“People inherently have so much trust in their doctor, but they don’t think about the cost ramifications when they get a recommendation for an MRI, for example,” Gasteazoro states. “There is a significant difference in cost between getting an MRI at the hospital where the doctor is employed versus a freestanding facility. However, the member doesn’t usually think about engaging with the health plan for that.”

Health plans must get the consumer to understand how their behaviors, including those recommended by their doctor, impact them from financial and quality perspectives. This depends on communication—the other top pain point for health plans.

“Healthcare still doesn’t know how to communicate with members because of the regulatory environment,” Gasteazoro says. “We have to send mail because we have limitations on text messaging, and we can’t necessarily do outbound calling with interactive voice response. So, we are not meeting members where they are.”

Uncovering how members want to communicate and when is vital to improving member engagement across populations. 

“All the investments that payers are making irrespective of line of business, whether they are products, features, or partnerships, don't matter if people aren't using them,” explains Gasteazoro. “It is critical for every health plan, as part of their overall marketing strategy, to align a member engagement strategy that meets members wherever they are. But that’s really hard to do in healthcare because that implies you have to customize everything.”

Plans need to have a robust communications strategy to tailor communications. Companies in other industries have executed similar strategies, for example, airline companies leveraging omnichannel communication methods within a single app to offer AI-based chat, human representatives, and self-service shopping.

“In healthcare, that just doesn’t quite exist yet,” Gasteazoro explains, even if health plans have omnichannel communications in place.

Communication, whether via chat, phone, text, or mail, must be meaningful. Members, particularly in the Medicare and Medicaid spaces, already receive a plethora of mailings and other communications, and as consumers, they are bombarded with advertisements. Plans need to tailor their communications to provide members with the most important information or assistance; otherwise, communications could be lost in the shuffle.

“Most health plans do a really good job of integrating tech strategies, mail strategies, digital strategies, and so on. But it’s less about how great of a job they’re doing and more about how these different strategies weave together, so they understand when a member ingests communications via text, mail, or email,” Gasteazoro stresses.

A robust omnichannel communications strategy is key to achieving ROI on tailored member health and wellness programs.

Health plans create programs based on behaviors or outcomes they want their members to achieve, whether it is managing their diabetes or navigating them to higher-value utilization options. To be successful, plans need to ask themselves what specific problem they want to solve, what outcomes they want to achieve, and what success means. These are foundational components of program design that plans can use to tailor programs, according to Gasteazoro.

Plans then need to execute their programs. What are the communication channels and frequency? Do plans need to use triggered communications or broader communications? What additional support will plans offer if members don’t interact with the communications?

“Program execution and feedback are very important because you should be monitoring the performance and expectations around those communications,” Gasteazoro says. “Health plans should also think about where they stand from an ROI perspective. Is the investment meaningful? Are they getting feedback that implies a potential transition or shift in strategy?”

Health plans have had more success garnering feedback in the commercial space because of market dynamics. In contrast, plans encounter challenges in the Medicare and Medicaid space because of CMS requirements.

Focusing on member engagement can help plans overcome the challenges of program design and execution to improve outcomes for members and payers. 

Member engagement is personal; every population and every member has different preferences for communication and interaction with their health plans. Personalization is key, but health plans must fortify the foundation of member engagement to offer populations the experience they need from healthcare.

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SmartShopper Propel makes closing care gaps easy and convenient for healthcare consumers. With an omni-channel approach, Propel focuses on meeting the consumer where they are to build engagement and trust, enhancing your quality ratings. Whether focused on helping with risk adjustment or lowering total cost of care, Propel is there to meet your plan goals. To learn more contact us at [email protected] or download our whitepaper.