How to Improve Patient Centricity for Commercial Health Plans

A May 2022 report by McKinsey identified patient centricity as one of 10 big shifts that will affect the future of healthcare delivery in the USA. For commercial health plans, in which health insurance and healthcare delivery have converged, that future has arrived. Every health plan interaction with a patient — a health plan member or beneficiary — is a moment of truth for providers looking to enhance patient experience.

At every step across the patient lifecycle, a health plan is challenged to effectively apply everything that the insurer knows, or should know, about the patient and their needs. A health plan is expected to identify the healthcare resources which are or need to be available  to meet those needs and the expectations of stakeholders such as employers or government. The inflexibility of otherwise reliable legacy systems and the data and business siloing that is so common in a health plan enterprise are significant obstacles to successfully meeting this challenge.

From a healthcare delivery perspective, patient-centric care means that a patient will receive the right treatment at the right time and through the right care delivery channel each time. With a central role in the management of patients’ care across all their providers, a health plan is expected to enable the effective delivery of patient centric care. The benefits of effective patient centricity include better health outcomes, lower healthcare costs, and increased patient and stakeholder satisfaction. In a competitive market, ineffective patient centricity negatively affects all these key components of the experience and imperils the health plan’s retention of this business. 

How can a health plan achieve effective patient centricity?

How to Fix Common Errors with Patient Engagement

In a March 2023 article McKinsey observes, “The healthcare industry is confronting an imperative not only to meet the evolving demands and expectations of consumers across the end-to-end healthcare journey but also to mirror the experiences consumers commonly enjoy when engaging with other sectors.” Achieving patient centricity means overcoming the limitations of reliable legacy systems, traditional siloing of products and lines of business, and old habits. From a technology perspective, some examples of the way that a health plan can improve patient centricity include:

• Drive member and beneficiary initiatives with data ingestion that drives patient-centric engagement across lines of business. Health management, treatment management and health benefits campaigns fail to use member data to guide campaign targeting, messaging, and communication preferences, resulting in failure to effectively identify and engage the members.
• Use predictive analytics to proactively steer patient behavior in the direction of better outcomes, reduced costs and improved satisfaction.  Consider elaborating upon existing simpler analytic approaches with responsible AI and machine learning. Pre-authorization communications are fraught with error and duplication, which needlessly encumbers the timely approval and delivery of care.
• Leverage technology such as a decision rules management systems for agile, transparent business user management of patient engagement without encumbering IT. Pharmacy benefit management systems are often out of sync with dispensing, which creates member confusion and may also impair medication adherence.
• Use a modern customer communication solution to enable smart, lifecycle communication strategies for patient convenience, ease, and personalized treatment through intelligent, omni-channel two-way communication, at scale. Consistent errors in member communication harm the members’ and their employers’ satisfaction with the health plan, which imperils retention of the employers’ group health business.

The advantages of a holistic, member-centric approach to healthcare and the impacts of the failure to achieve member centricity are clear. The days when your family doctor might have coordinated your care across all your healthcare providers are long past. For many healthcare consumers, their health plan is the only place where the effective management of all their healthcare across all their providers can come together.  From health insurance policy application, underwriting, enrollment and onboarding to pre-authorization and claims management to clinical, care, disease, and population health management to assurance of payment integrity, the expectation of patient centricity across the lifecycle is relentless. 

Achieving member centricity requires that a health plan leverage all the data that they gather across the lifecycle and responsibly apply trusted and emerging analytic approaches like AI and machine learning across that lifecycle.  The emergence of AI decisioning platforms with open, unified, API-first architecture that have solved the most complex and demanding requirements of enterprise environments around the world has empowered organizations to break down silos, increase collaboration, and power their workforce to achieve customer-focused digital transformation.

The Impacts of Success or Failure to Achieve Patient Centricity

Health plan members may become fatigued with outreach that is not relevant or has errors because the health plan fails to effectively leverage claims and health data in their engagement initiatives. This kind of fatigue impairs confidence in the health plan’s ability to effectively manage their healthcare. By effectively leveraging claims and health data in engagement, the health plan will assure that they effectively identify and engage each member.

Pre-authorization of healthcare is a common and significant “moment of truth” in healthcare delivery. It is also a key “moment of truth” in a health plan’s relationship with their members. Timely, explainable and accurate pre-authorization that includes easy, effective two-way communication between the health plan, the healthcare provider and the member is a key example of effective member centricity.

Pharmacy benefit management is also a common and significant “moment of truth” in healthcare delivery, and when it concerns medication for treatment of chronic conditions, it consists of recurring “moments of truth” that have consequences for the long-term health of the member. When a health plan leverages accurate and up to date data on the dispensing of medication for a chronic condition, for example, the health plan effectively engages the member in a key aspect of their health management.

Finally, accurate member communication is a key element of satisfaction with a health plan and that is one of the keys to the retention of an employer’s group health business.

With the emergence of “health tech” competitors, traditional health plans will need to demonstrate partnership with their members and beneficiaries — and on behalf of employers and other key stakeholders — to improve member and beneficiary health, reduce costs and help patients navigate the healthcare system.

How FICO Can Help You Achieve Patient Centricity

• Learn how FICO drives smarter, faster, and more insightful decisions for healthcare insurance providers
• Read Transforming Digital Healthcare Claims Administration | FICO
• Explore FICO Platform
• Discover why health plans and administrators worldwide are turning to FICO platforms