Charting a better user experience with health insurance -
Old infrastructure and new challenges complicate the customer journey

A key piece of the puzzle was enabled when Cognizant’s TriZetto partnered with Orion Health, a company that aggregates and analyzes claims data and clinical data from electronic medical records (EMR) systems. “They are experts in bringing clinical data out of proprietary systems such as EPIC and other EMR systems,” Gleason explains. “This provided us with the clinical integration piece.” Being able to see clinical data and real-time financial data in context is essential to providing a consistent and informative customer experience.

That experience needs to flow from a comprehensive model. “The fragmented nature of healthcare in general makes it difficult to navigate,” Gleason continues. “Customers need to be able to move from selecting a plan to participating in a network, picking one or more physicians, checking their ratings and then being able to see their own healthcare records.” One of the most aversive parts of the customer experience is receiving the bill. “Given the out-of-control costs, streamlining the process is essential,” Gleason emphasizes.

The role of TranZform is to orchestrate all the processes and data that are needed to manage healthcare within the context of an insurance company. By integrating information for a growing number of phases in the customer journey, the product will help companies make the transition in an environment that still has a lot of unknowns.

Value-based care

Another factor that may well help both insurance companies and patients is the steady move toward value-based care. “Up until now, medicine has been based on fee for services,” Gleason explains.“Going forward, keeping the patient healthy will start to dominate the process.” Already in place in Medicare, that approach reduces reimbursement to hospitals if a patient returns within a month for treatment of the same condition.

The trend toward value-based care can be positive for both consumers and providers, according to Cordina. “There is more shared risk between the providers, health insurers and consumers,” she says. “The healthcare system is made more accountable.” Insurers can reduce the costs of healthcare by engaging customers in wellness programs, managing chronic conditions such as diabetes and reducing the number of emergency room visits and unnecessary tests or procedures. Those actions also improve patient health and promote positive outcomes.

Value-based care should have a positive impact as the focus shifts from payment for services to payment for maintaining patients’ health. Given that about 80 percent of healthcare costs are attributable to chronic conditions, even a small improvement in that group will mean a big drop in expenses. Better customer engagement is related to improved outcomes for patients when insurance companies help the customer locate appropriate care. As noted in a report from McKinsey, “Great Customer Experience: A Win-Win for Consumers and Health Insurers,” a positive correlation can be found between customer experience and financial performance, if the plan and the customer segments are well matched.

The impact of this change is that the patient care paradigm will alter and other avenues of service will open. For example, current cost models do not provide for doctors to get paid for sending emails or having a detailed conversation with the patient, but if that can solve the problem, it benefits both sides. “In the future, we expect more telemedicine,” predicts Gleason. “Patients will take a video of their throat or their skin, and the doctor can diagnose a sore throat or a lesion.” The patient does not have to leave home and the doctor can see patients more quickly. The virtual meeting can be recorded for future reference.

Rating the experience

Clarabridge, a customer experience management company, recently introduced a product designed specifically for health insurance companies. “Natural language processing is built into the solution and is optimized for medical discussions,” says Julie Miller, VP of product marketing at Clarabridge. Feedback can be obtained by plan type and presented on a dashboard correlated with the member journey. Sentiment across different points of the journey and different plans can be reviewed, and insurers can drill down into specific lines of business to gain insights about why members are particularly happy or dissatisfied.

One leading health insurance company launched that solution in response to its retail business growing from a very small group of members to nearly a million in a very short time, primarily due to the ACA. Those new members had high expectations for unique, personalized experiences that were not being met. Instead of relying solely on traditional metrics, the company began using Clarabridge’s solution to collect and analyze member feedback from 22 channels, including call transcripts, agent notes, secure messages, social media and surveys.

Through that analytic process, the health insurance company could identify some additional areas for self-service, including the relatively simple transaction of canceling a policy because the policy holder had passed away. Within six months, the company had identified opportunities that would improve the member experience while saving the business $5.5 million. In addition, a process was established for determining channel preferences for its total base of 14 million members, which will help the company determine priorities for developing new self-service capabilities.

“Our analyses help health insurance companies understand which plans perform best with certain age groups or demographics,” says Miller. “Millennials are much more likely to talk about products online, so their comments get amplified. Health insurance companies are now using social media channels to monitor feedback and engage with members. Not only do those digital platforms help companies save money by resolving issues that would ordinarily be directed toward a call center, they also help members optimize their choices.”

Wellness leads the way

Consumers have been embracing healthy behaviors more than in the past, and although the trend may in part be based on a desire to lower their own healthcare costs, that is not the whole story. People are genuinely interested in improving their health. Over 20 million FitBit customers were actively using their devices as of the beginning of 2017, and that group is only about a third of the worldwide total. More than 50 million Americans belong to a health club, and some Medicare supplement plans provide free memberships to such clubs.

When used in conjunction with their healthcare plans, such engagement can be a win-win situation. “More tools are available to track health and fitness,” says Cordina. “We are seeing innovations in both the health insurers’ plans and from employers.” She also perceives more active engagement on the part of insurance companies promoting preventive care. For example, some have engaged a third-party service to call customers and remind them about annual physicals.

Although the current environment is challenging, the long-term outcome could be improved patient health, enabled by greater customer engagement and a new cost model. With better customer-facing interfaces, smoother workflows and two-way outreach, the population could be healthier and even experience some moderation in costs.