Why member experience, healthcare costs are key for payers

Redefining the member experience

As promoting a better member experience continues to loom large for health plans, the Forrester researchers stressed the importance of real-life, compelling storytelling. Payers can reach members more authentically by demonstrating competence, reliability and accountability through the stories of real health plan members, the researchers said.

Moreover, leveraging AI where applicable will be key. AI agents can make it easier to summarize previous member interactions and put them into the context of a current request. This is important as first-contact resolution is among the biggest factors swaying a member experience and human-powered call centers are encumbered by high call volumes and complex queries.

Finally, the authors advised cutting administrative overhead and workflows that hamper patient and provider experience. Three-quarters (77%) of providers think insurers create extra hurdles for care, and only 20% agree policies and procedures put in place align with patient-centered care.

Payers should consider the provider experience and invest in tools that create more seamless data flow and exchange. Likewise, gold carding and waiving prior authorizations will be key, the authors suggested.

Invest in cybersecurity protocols

With the 2024 Change Healthcare cyberattack, health data security is top-of-mind for nearly every healthcare stakeholder. There are costs associated with poor cybersecurity, not to mention the negative implications for consumer trust. This comes as health plans work to integrate more digital health offerings -- and therefore introduce more digital risk -- to support their members.

With that mind, health plans should concentrate on cybersecurity, starting off by embedding cybersecurity considerations into every health plan decision. Specifically, the researchers advised a Zero Trust eXtended architecture, meaning that no one -- even employees -- automatically gets access to sensitive data or systems.

Next, the researchers advised payers to invest in formal governance and training to improve tech literacy among employees. This includes regular updates to cybersecurity measures.

Finally, the report authors urged health plans to think twice about their AI providers.

"The risks of hallucinations, bias, and data privacy breaches are the same regardless of whether AI is built internally or embedded in third-party software," they wrote. "Establish evaluation standards that are used consistently across the organization."

Leverage and partner with digital health companies

Digital health companies emerged to fill gaps in the healthcare and health plan experience, but according to the report authors, coverage limitations and other factors kept the tools from fully flourishing. This has opened the door for health plans to partner with digital health companies to reach certain populations.

Payers should ensure they are targeting high-cost conditions, such as musculoskeletal and cardiovascular conditions. The Forrester researchers indicated that digital health tools tailored to these two areas have been proven to boost outcomes and have a broad population base, which can ideally yield ROI.

Engaging more tech-savvy seniors will likewise drive performance. Meanwhile, ensuring proven performance improvement based in outcomes data will be essential.

Leverage value-based care to boost member experience

Value-based care has reached a stagnation point, many experts on both the payer and provider side say. But according to Forrester, health plans that bet big on value-based care could see benefits in terms of consumer experience, clinical outcomes and cost efficiency.

Investing in better data sharing between the payer and provider could compel greater provider buy-in for value-based care models. Additionally, health plans might drive better engagement defining what value-based care actually is and how it can benefit consumers.

Payers do need to anticipate market entry of direct primary care providers and other entities that contract directly with employers. Greater cost-sharing could make the case for employers to continue contracting through health plans, the Forrester researchers suggested.

Address healthcare affordability crisis with innovative benefits

Healthcare affordability has become a top-of-mind problem for most healthcare consumers. Health plans should experiment with more innovative benefits plans to provide diverse options that deliver on what their members need.

For example, health plans might offer customized add-ons, such as ways to expand prescription drug coverage, waiving of primary care cost-sharing or opt-ins for digital health tools.

They might also invest more in member education, particularly around HSAs and FSAs that can be leveraged to pay off medical debts. Similarly, health plans can invest in better patient navigator services or tools that let members shop and compare specific health plan options.

Prepare for primary care vertical integrations

Vertical integration, acquisitions and partnerships are all expected to be more feasible under a second Trump administration, the report authors explained. This opens the door to many opportunities to implement value-based care, but it is also cause for caution as consumers face higher costs and more complexity.

"Develop a clear plan for integrating primary care practices into existing operations, and be mindful of affordability barriers for consumers," the report authors advised. "Align businesses to serve unmet and underserved customer needs, and inventory both processes and technologies to ensure seamless care coordination to reduce avoidable costs."

Integrated care options could streamline the healthcare customer experience. Additionally, waiving cost sharing for primary care services could eliminate some cost barriers.

On the provider side, payers need to stem and prevent provider burnout and workforce shortages. Leveraging tools like generative AI could allow providers to focus away from administrative tasks and onto more high-level problem-solving. However, payers need to partner with provider organizations to continue to support more inclusive workplace cultures and cut out bureaucracy.

Reimagine PBMs

Finally, health plans should be concentrated on promoting affordability and price transparency. After all, prescription drug affordability is a significant hurdle to medication adherence and, thus, good outcomes.

"No one wins when medications and critical treatments are inaccessible or when pharmacy deserts spread," the report authors wrote. "By providing real-time access to cost information for prescription medications, explaining formulary choices, and disclosing financial relationships with pharmaceutical manufacturers, PBMs can help customers make informed decisions and build trust."

PMS should support the pharmacy as a patient engagement vehicle. Supporting models that promote health literacy, patient navigation about health benefits and medication adherence will be high yield as patients tend to visit pharmacists more often than primary care.

Collaboration with non-traditional healthcare actors could lower costs. For example, partnerships with Amazon Pharmacy, Mark Cuban Cost Plus Drug Company and companies like Hims & Hers have offered alternatives to high-cost drugs.

"Health insurers must adopt novel supply chain approaches, test new business models, and push to overhaul pricing," the report authors concluded. "Regulators should enforce cost-effective prescription drug paths where possible."

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