Demonstrate the ability to efficiently deliver concierge medicine through virtual locations of care.
By Proteus Duxbury | Published October 03 2016, 3:42pm EDT
Healthcare reform, technology advances and the rising cost of care is changing the way insurance is purchased and utilized, while empowering the consumer to make their own healthcare decisions. As a result, more money per member per month is being invested within the individual consumer segments.
According to research by PA Consulting Group, growth in private exchanges is estimated to reach 30 million by 2019, and by 2020 we expect the majority of consumers to be purchasing insurance through a public or private exchange.
As this consumer-centric “retail” payer market takes root, there will be a slow migration of responsibility for engaging the health plan consumer away from primary and secondary care physicians to payers and payer contracted and directed healthcare professionals.
Payers that thrive in the new consumer-focused, individual marketplace will be the ones that focus on delivering a consumer-centric member experience, putting the consumer at the center of everything.
To be truly consumer centric payers will need to:
- Improve first-contact resolution and better care coordination and management across payer, provider and other stakeholders such as the insurance exchange and brokers. Including full visibility of all a members interactions with each and according to consumer preferences.
- Become a one-stop-shop for all a consumer’s healthcare needs and to provide them with the ability to more fully own their health outcomes.
- Demonstrate the ability to efficiently deliver concierge medicine through virtual locations of care.
- Offer consistent experience across different communication channels such as digital, web, phone and interactive voice response (IVR.)
- Integrate the needs of the consumer across the end-to-end care delivery value chain, including: virtual office visits, retail service centers, scheduling of physician services, simplified referral/authorization processing, managing health savings accounts, supporting services such as health club membership and discounts, more in home treatment and online applications.
Well-thought out and executed consumer engagement programs can convince consumers to enroll, support plan loyalty and member retention, increase quality and support care management and reduce medical costs. The total financial benefit of implementing consumer engagement programs could be as much as $250 million in savings and additional revenue for a mid-sized payer. The benefit to a large national payer would be approximate $500 million.
However, payers are reporting numerous challenges in achieving ROI from their engagement initiatives. Moving from strategy to execution is a struggle for many organizations with a lack of clarity around how to achieve tangible benefits and having a clear implementation roadmap and plan. Payers need to be nimble in realizing the planned benefit, but we see many companies struggling to be agile in the delivery of change.
Many consumer segments are notoriously difficult to engage. Consumers struggle to make smart decisions about their healthcare for a number of factor, including complicated terms, lack of information, lengthy explanation of benefits and opaque cost requirements. Some larger payers have partially addressed this challenge, but small to medium-sized companies may need to invest in helping their consumers navigate their organization more effectively.
The data needed to support pricing transparency and decision support is often missing or of poor quality. The current generation of technologies, such as CRM and care management tools, are not delivering meaningful engagement, and efforts to upgrade or enhance them are struggling. Integrating the necessary IT systems to provide the data needed to create a seamless experience is difficult.
In a recent study published in the Journal of Health Affairs, “secret shoppers” posing as patients were able to successfully use a provider directory to schedule an appointment with a physician less than 30 percent of the time. This was primarily because the available provider data was out of date.
Long-term engagement using new patient-directed care models, such as telehealth and wearables, is difficult to realize. After 15 months of usage, sustained patient use of these technologies typically drops off to about 50 percent.
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