How Health Plans Use Communication to Enable Member Empowerment

Health plans are making concerted efforts to become advocates for their members, working on behalf of the latter to ensure access to high-quality, affordable healthcare. Some have even set bold goals to build strong, collaborative relationships with members to improve overall care management. Trust is the organizing principle for meeting the clinical, behavioral, and social needs of beneficiaries.

For payers to become member advocates, they must build trust with their members. While much of the national focus on healthcare focuses on utilization and cost, the member experience — the prime target of health plan digital transformation efforts — traces its starting point further back as consumers consider their options when a health need arises. Given that healthcare is a journey, it’s best to start at the beginning.

Nearly a decade ago, Levesque et al. (2013) highlighted the “central” importance of accessibility — from identifying health needs to receiving care services — to the healthcare system and laid out five dimensions of accessibility: approachability, acceptability, availability, affordability, and appropriateness. For a healthcare consumer to access care, they would need five corresponding abilities to understand their health needs, seek out services, reach care facilities, afford those services, and engage with the health system.

Approachability is a key element of healthcare access, enabling individuals with health needs to identify available services to improve their condition. As noted by the authors, transparency and communication are vital to achieving approachability but can only meet with success when appropriately tailored to the health literacy and beliefs of consumers. Here is where a healthcare consumer’s interaction with the healthcare system begins, and so does the ability of healthcare organizations to build trust.

Approachability as a health plan

Meeting the needs and expectations of healthcare consumers where they are is key to the near-, mid-, and long-term success of payers. A member’s first interaction with a health plan represents a pivotal moment for the latter to understand the former’s needs and provide options.

“Approachability is highly meaningful to members for them to feel empowered,” says Zelis Vice President of Product Innovation Madison Goldfischer. “But this is gained through a combination of omnichannel and straightforward opportunities to engage, matched with optimized choices that allow members to make the right decision on their own time. This embodies the idea of ‘choice optimization’ when thinking about creating an approachable environment — ensuring members feel empowered.”

With member engagement representing a vital component of member empowerment, the former must take into account the impact of health literacy if the latter is to be achieved. In short, health literacy presents a common obstacle to effective communication with consumers. According to the National Center for Education Statistics, 53 percent of adults in the United States had intermediate health literacy, with 36 percent having basic or below basic levels. Troublesomely, these findings published in 2006 found that adults with the most significant health risks had the lowest health literacy skills.

Health plans, therefore, have an opportunity to remove complexity around healthcare and share information that can become actionable in the hands of members. For example, explanations of benefits are a staple of today’s consumer experience, but they are not, in fact, member-focused given the impetus behind them.

“Today’s explanation of benefits has evolved alongside the managed care sector as more of a regulatory must-have, evolving out of an overall set of industry standards that govern how claims are submitted and paid for. As with most industry standards — for example, IEEE Standards for engineering – they are designed to optimize industrial processes across organizations,” Goldfischer emphasizes.

“So, in effect, EOBs were not designed to be consumer-friendly at all. They are simply meant to satisfy regulatory requirements. There is a huge opportunity to support these experiences to drive clarity and use consumer-friendly language as opposed to industrial terminology that is confusing — transitioning these communications from ‘needed’ items to ‘must-have’ for consumers.”

Sharing the right kind of information at the right time is key to empowering members, especially as the healthcare industry shifts from sick (i.e., expensive) to preventive (i.e., affordable) care. In truth, EOBs could be the only interaction members have with their health plan during a benefit year. Before the onset of COVID-19, researchers already showed that low health literacy of health insurance contributes to care avoidance, both preventive and non-preventive, citing the need for “plain language communication” to counteract the phenomenon.

“I do not know how many times I have had people, even family members, ask me about how to read their benefits coverage,” Goldfischer reveals. “There is even clear evidence that lower health literacy is associated with skipped or delayed care. The more we can simplify insurance language while simultaneously driving understanding of how to use them, the more we can possibly help improve outcomes over time.”

According to a Zelis survey of 1,100 health plan members, 30% of members cite communication accuracy and clarity as drivers of low satisfaction levels, with 16.7% of respondents reporting that proactive assistance and communications represented the most important change that would improve their healthcare experience.

Individual respondents sought clearer explanations of long bills, certain codes, and medical terminology so they could better understand their health needs and take the necessary steps to improve their health status.

With the pandemic having created additional care gaps — particularly missed preventive screenings — health plans can seize on this moment to advocate for their members through clearer communication, streamlining access to services, and facilitating effective and affordable care management. Doing so requires payers to understand both the health needs and abilities of members to interact positively with the healthcare system and make it more approachable.

“If plans are to make headway providing greater transparency and predictability to members, they will need to use all available engagement channels to position themselves as true advocates,” says Goldfischer.

With the support of a member-focused health plan, members can develop greater trust in the plan and a willingness to take more ownership over their care.

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About Zelis Member Empowerment

An empowered member is an engaged member.

Zelis helps payers increase member satisfaction and optimize the value of care through our member empowerment platform. Zelis has a unique focus on the member experience. Providing clarity, control, and guidance across their healthcare journey. From finding the right provider, confident cost estimates, incentives for care selection, compliant EOB solutions, guidance in understanding bills, to options for secure payments. 

To learn more and stay up to date on our newest research in the area of digitally empowering members, please click here.