Next best action in action: How to treat plan members like consumers

One of the biggest problems in healthcare can be summed up in three familiar words: failure to communicate.

And the solution sounds just as simple: next best action. The term refers to an approach that Internet giants like Amazon, Netflix and Pandora use to help guide consumers toward the choice that is best for them given the abilities and constraints of the enterprise they are engaging with.

The same approach can be applied to health plan members. Take a hypothetical member who is 40, due for a mammogram, also needs a diabetic eye exam and whose primary care doctor just left the network. In most health plans today those interactions might be handled by three separate departments, each providing individual communications that can overwhelm or confuse members. Worse, the member might receive her screening appointments first, only to find out her primary care physician has left the network. That’s what Amazon executives call a negative experience; in the cutthroat competitive atmosphere of online retailing, negative customer experiences can be devastating.

The same mentality is beginning to take root among some health plans, who are increasingly feeling the same level of competitive heat. The central principle: customers come first. Then it’s a matter of building systems to communicate with customers in ways that motivate better decisions to lower costs, promote better health and increase loyalty.

One of the challenges for health plans is they have limited opportunities to interact with members and many of those opportunities arise in the context of negative events such as acute care episodes, illness or worrisome diagnoses.

Insurers and plan administrators, meanwhile, have multiple conflicting priorities on their end. Unlike Amazon, which simply wants to throw the most enticing ideas in front of customers to inspire their next purchase, insurers must decide which of their many priorities should get top billing. Remind members to reenroll next year? To follow diabetes care guidelines? Nudge members toward getting answers from the website instead of the more expensive call center? In most health plans today, there’s simply no governor regulating limited interaction time with the consumer.

Adding to the complexity, plan sponsors have their own priorities that don’t always align with those of insurers. Some employers limit how health plan administrators interact with their employees because they perceive some interactions as a hassle for the employee. Others see their healthcare benefits as a key element of corporate strategy that helps them manage costs and recruit and retain talent. They want their plan to be perceived as a friend of the employee, not some faceless entity that specializes in saying no.

Plan administrators, meanwhile, may be focused on consumer satisfaction metrics that are built into their contracts and compensation models while also trying to reduce back-office expenses, especially at their call centers.

So, the determination of the right interaction for an individual plan member at any given moment is complicated, and today it is poorly managed by insurers.

The Answer: Next Best Action
None of the complexity above matters to consumers, who increasingly compare health plans not with each other, but with the buying and servicing experiences they see from their favorite brands. To win over these customers, insurers must build trust. And the key to trust is a positive member experience.

In consumers’ everyday interactions with their favorite brands, the experience is based on past interactions, historical interactions of like individuals, the financial goals of the brand (e.g. encouraging an add-on sale), and in turn a prediction of what the next best action is for that individual. Amazon might examine past purchases and perhaps some demographic information to recommend other products that individual might like. Netflix and Pandora use past viewing and listening behavior as well as that of others to predict what the subscriber might like next.

Healthcare presents a huge opportunity to use next best action to provide a more positive experience. For the 40-year-old member above, that might mean putting “time to select a new doctor” at the top of the communications queue and subsequently sending out screening notices that are coordinated with the member’s selection of a primary care provider.

Managing Communications Channels
Healthcare, of course, is a lot more complex than binge-viewing or gadget-selling. At the highest level, health insurers have two forms of consumer touch at their disposal:

- Outbound: Communications with members should be prioritized and coordinated so they aren’t arriving haphazardly from every part of the enterprise. They also should be reengineered to reduce reliance on paper mailings, now the predominant form of outbound communications among health insurers. Email, SMS text messaging, mobile app notifications, and other digital communication media have their limitations, but they are increasingly finding their way into direct to consumer interactions from insurers.

- Inbound: Next best action technology can work in call centers too, guiding agents through their interactions with members. Suppose a member is known to have a chronic condition like diabetes. During an inbound call about a claim, a next best action application can prompt the agent to also recommend to the member that they be redirected to a nurse. The agent may only have a few seconds of a member’s attention, so the art of engaging them is to establish credibility and then direct them to the next best action – in this case, toward more intensive medical attention to improve the member’s health and reduce the cost of care. Also, use of member portals is steadily increasing at some health plans. These websites should be personalized to better enable members to obtain information and set their preferences for outbound communications – would they prefer email, phone, instant message or snail mail? And as members navigate the website, next best action technology can deliver popup windows based on the priorities of plan administrators and plan sponsors.

Barriers to Implementation
Health insurers face serious obstacles to creating a seamless, integrated system through which next best action capabilities can deliver results. A typical carrier’s technology infrastructure is often fragmented and siloed due to decentralized IT investments that have been made on a department by department basis over many years, and sometimes reflecting a series of acquisitions. This fragmentation results in various platforms housing different types of data such as member contact information, member risk profiles, claims data, health information and even billing history. Individual members might even be known by different names and ID numbers on those disparate platforms.

Health insurers and members also might have misaligned goals. To achieve earn trust, insurers must seek to understand the member’s priorities and incorporate that knowledge into all communications.

Insurers also tend to have multiple teams attempting outreach with customers at the same time, often with competing goals. Even if the enterprise can identify the next best action, it’s difficult to prioritize one team’s goals over another. The problem is made even more complex in an environment in which capabilities are managed by outside vendors (transparency tools, risk management algorithms, outreach for gaps closure, etc.).

Adopt Slowly, But Deliberately
Given this complexity, one approach is to apply next best action capabilities across subsets of activities. Focus on five of 20 interactions to start, instead of all 20 at once – both outbound and inbound. An analysis of volume of interactions, high value targets, interaction yield, and financial impact in the context of enterprise strategies can often point to the first interactions which merit attention and investment. This analysis should also include focus on consumer priorities and should ideally be implemented in a highly personalized and user-friendly interface.

One of the primary inbound interaction channels will be the member portal, and enterprises should attempt to make it as easy to use and as intuitive as Amazon’s. Companies like Zipari, where I am an advisory board member, use APIs to collect and analyze data on disparate corporate systems, ascertain next best action at the individual member level and present it through their customer-facing applications. Next best action capabilities can also be developed in a standalone application and delivered to native platforms.

Based on the activity we see in our research and among our clients, the one thing health plans certainly should not do is stand still. It seems clear that as consumers are increasingly responsible for the cost of their own care, the more discerning they will be in assessing the quality of their interactions with their health plans. We found in a research project that we completed in 2017 that more than half of health plans report increases in their budgets related to consumer engagement, and nearly 90% report that top leadership is more focused on consumer engagement than in the prior year. Investments in next best action capabilities and the applications that enable them are smart bets to get ahead of the pack and avoid being in the position of playing catch up.

Copyright © 2023 Becker's Healthcare. All Rights Reserved. Privacy Policy. Cookie Policy. Linking and Reprinting Policy.


Featured Whitepapers

Featured Webinars