How Health Plans Build Trust to Become Member Advocates

For the past two years, the healthcare industry — from lawmakers and regulators to payers and providers — has made strides in supporting members through a pandemic by providing convenient access to a more digital and streamlined healthcare experience.

Despite this progress, consumers still view their interactions with their providers as generally positive whereas those with their health plans remain relatively negative, a recognition that has led insurers to work on changing long-held perceptions of their role as simply a payer.

A great example is how they convey the financing of care received. Regulations — from state to federal law (e.g., ACA) — have required health plans to furnish members with an explanation of benefits (EOB) regarding claims for health services to be reimbursed. While these documents are necessary for regulatory compliance, they provide limited value to members attempting to calculate their financial responsibility and determine where to receive care simply based on their intended purpose. 

“Healthcare has a ‘CVS receipt’ problem, a list of stuff that consumers don't care about at the end of the day. Instead, they want to know the cost to them, when payment is due, and the next steps in their care,” says Zelis Vice President of Product Innovation Madison Goldfischer.

“Health plans have the difficult job of helping steer their members through the myriad of regulatory, compliance, and complicated world of healthcare, on top of finding ways to reduce care expenditure, and therefore this complexity sometimes creates distrust through poor experiences and mismatched consumer expectations,” he continues, “and now they are trying to see themselves more as curators of care, where they’re trying to create access steerage opportunities with aggregated and ranked points of access which can be broad — from wellness to chronic care management.”

That history is truly problematic. Before the pandemic, the Advisory Board Health Plan Advisory Council highlighted sobering facts about overall consumer distrust in payers. Nearly half of consumers in the United States (43%) do not trust their health plans, with insurers ranking behind airlines and wireless carriers in customer experience ratings — the reason being that health plans can be viewed as impersonal, complex, and opaque in their dealings with potential and existing members. What’s more, consumers have much more trust in physicians, pharmacies, and health-related websites than health plans, for which still only 14% reported high levels of trust.

Member satisfaction is rising thanks to the work of health plans prior to and throughout the pandemic. But frustration remains around understanding care options and costs. Zelis is studying this problem and recently found that of 1,100 members surveyed, three-quarters rate their overall healthcare experience as positive. However, negative emotions emerge around provider options, costs, and bills — anxiety and uncertainty are two feelings impacting one-third of members. Clearly, health plans have an opportunity to allay member concerns and become a resource for accessing accessible and affordable care.

Earning member trust

As health plans work to become advocates for their members, they must listen to the latter to better understand their needs, meet and support members where they are, and leverage new and existing data to drive member-centered innovation.

Creating the right experience

Each member has her own healthcare experience, which is unique and personal. Therefore, health plans must acknowledge and respond to this emphasis on personalization.

“Health plans have not traditionally been member-focused — they’ve been cost-of-care and employer/client-focused,” explains Goldfischer. “Often, payers have been guilty of building coverage solutions from the employer perspective, which doesn’t always match member expectations. Actually building experiences based on the problems, needs, and expectations of members will help to drive trust.”

Putting the proper focus on members requires health plans to develop core competencies related to creating clarity on optimizing members’ time spent and cost liability, empowering members to take more control over their care, and leveraging trust and understandable options to better guide them on what comes next. To truly be member-focused, a plan needs to know its members deeply, acknowledge the moment they are in, and offer the best-curated list of options to empower them.

“Health plans must be able to design services and functions to help support members through their issues and not have to worry about it at the end of the day – they must create true convenience,” adds Goldfischer.

Meeting members where they want to be met

Convenience is crucial to meeting the needs and expectations of healthcare consumers. But until recently, digital options for interacting with the healthcare system were few and far between. Accelerated by limitations imposed by the pandemic, health plan digital transformation can lead to greater convenience and satisfaction for consumers.

“Are you creating an omnichannel experience that is consistent across all of those channels? Many of the players in the space are behemoths of companies that don’t have high levels of consistency because they have 50, 100, or 200 different systems when attempting to consolidate and curate information,” Goldfischer emphasizes.

Smaller health plans find themselves in an advantageous position to be more flexible and agile in this regard. Their member base is narrower and they are unlikely to be consolidating many multiples of systems together. But what is sorely needed are the analytical tools to aggregate, analyze, and create actionable insights from data that is already on hand.

“This requires strong analytic minds, as well as core human-centered design strategies. The long-term issue is how to pick apart the right use cases,” Goldfischer observes.

Supporting rather than limiting choice

The customer is always right — except when the conversation turns to healthcare. Perception has it that health plans have a reputation for preferring reduced costs to member choice. Much more goes into a member’s decision to choose services than simply price.

“Today, many consumers feel they have little choice and options are dictated by the health plan. The member and health plan actually have the same end goal, the right care for the member’s need,” Goldfischer notes.

“We need to give members the information on that choice and possible lower-cost, quality-equal alternatives to have a complete view before making their decision,” he continues. “And once they make an educated decision, we need to succinctly explain what the charges mean upfront before the visit, support them with payment options, and help the member anticipate additional costs. That could mean breaking down payments to subscriptions or creating pay-later functionalities and enhancing price transparency solutions. All of those things are on the table now and could support an incredible experience for the consumer, experiences that mirror how they interact with the world outside of healthcare.”

In short, health plans must prioritize providing members with clarity, control, and guidance relative to their healthcare experience.

With health plans wanting to gain consumer trust and become advocates, they need to think more about what they can do for members than what members can do for them.

We need to engage the member in those situations, even earlier upfront than we would, taking the member and payer problems further upstream than post-adjudication. This comes back to building member-driven actions using all the available data — making these engagements collaborative actions as opposed to just proactive messaging.

For health plans to become advocates for their members, they must focus on building trust directly with members. That comes from being transparent, understanding the needs of members, and empowering members to be decision-makers in their healthcare experience. By being responsive to the needs and expectations of consumers, health plans can design coverage and services that are genuinely member-centered.

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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.