Demystifying healthcare for members: 5 ways to bring clarity to the confusion


Probably the most common descriptor of healthcare today is confusion. New ACA requirements, employer changes to benefit plans, Medicaid expansion, individuals new to health insurance and purposeful obfuscation on the part of ACA opponents are adding significant confusion to the already labyrinthine healthcare "system". This confusion has and will continue to lead to inappropriate utilization, provider tension, lower quality scores, higher costs and an increase in appeals and grievances.

We encourage healthcare executives to Think Differently about how to bring clarity to the confusion. With the marketplace full of new healthcare options – now is not the time for status quo.

We suggest you begin by Thinking Differently with these five high impact recommendations:

  • Talk to your members

You’ve spent a lot of money to convince people to enroll in your plan. Now convince them that they made the right decision by being as easy to work with as possible. First, because confusion often starts among your own staff, make sure that your employees understand your products and services and can clearly answer questions from your members. Don’t just focus on your member service staff. Second, take every opportunity to talk to your members. One of the biggest obstacles to clarity is the complicated integrated voice response (IVR) systems most companies utilize in the name of efficiency. In our confused marketplace, each time you have a chance to “touch” a member, whether it is an in-bound or out-bound call, you have a chance to not only help them but also make them a positive representative for your company. During every encounter, make them feel welcomed to your plan.

Demystifying Approach: Think Differently about talking to your members. Turn off your IVR system and answer your member service and other phone calls by deploying friendly employees who can provide clarity to your members’ questions or issues. Also, use your team to provide outbound calls to talk with high-risk members before they need help. Don't skimp on this. It’s difficult to recover from a bad member service experience – invest in making yours the one to impress.

  • Incorporate member advocates into your care management programs

Many of your members need extra help because of complicating factors, such as multiple chronic diseases, behavioral health co-morbidities, or social, financial or cultural difficulties. Not addressing these often results in members turning to emergency departments or other healthcare providers who are not equipped to respond appropriately or in a cost effective manner. The best way to support these members is with advocates who are knowledgeable about community resources in your area and can help connect your members to the appropriate organizations. They can also assist members who need special help in understanding how to appropriately use healthcare resources.

An initial assessment or a referral from a provider or your member service or care management staff can identify those who would benefit most from a member advocate. The advocate could then conduct a more detailed needs assessment that would become part of the member’s care plan. Your member advocates should be skilled in working with people who are challenged by social, physical and/or behavioral heath issues.

Demystifying approach: Think Differently about care management. Incorporate advocates into care plan development to better support members with social, behavioral or cultural issues that impact their use of the healthcare system. The results will be reduced medical costs and improved member outcomes.

  • Integrate all member data

While there is a tremendous amount of member data available in most healthcare organizations, it is often overly complex, too aggregated or disaggregated to provide actionable information on a per member basis. The best way to provide better care management for your members is to have all of the member’s data available for your advocates, care management team and providers. Your system should be able to connect disparate sources of clinical and quality data and provide it in a comprehensive form to the entire care team, resulting in improved outcomes and reduced healthcare costs. This integrated system will also reduce the chance of unintentional non-compliance with regard to care gaps, grievances and appeals.

Demystifying approach: Think Differently about your technology solutions. Find a vendor who can provide you with comprehensive, fully-integrated platform that delivers information on a member-specific basis. The result will be improved health outcomes and a reduced opportunity for non-compliance.

  • Help your members get more involved in decisions about their health

One of the biggest contributors to mystification of healthcare arises from members not having the appropriate information and tools to be actively involved in decisions about their care. Shared decision making tools can help members manage a chronic health condition, decide on a treatment plan when several are available or learn how, what and when to communicate with their providers. Studies have consistently demonstrated that the more engaged members are in managing their own care, the better their outcomes and satisfaction levels and the lower their costs.

Demystifying approach: Think Differently about how to engage members in their care by providing them with the best tools available to make more informed decisions.

  • Provide alternatives ways to access care from providers

Access to appropriate care has become overly complicated, confusing and often not timely. Hospital emergency departments are taking advantage of this by touting low wait times and promoting care delivered at the most expensive, least appropriate place possible for most health problems. Whether your members are dealing with serious health problems or relatively routine issues, the current system often does not meet their needs and leaves them frustrated.

Members with significant health problems often experience transportation issues, office visits with providers that are too short to fully meet the their needs and confusion about their medications, treatment guidelines and prognosis. The result is often a cyclic visit pattern to the ED, more specialist involvement, readmissions and poor health outcomes and higher costs. The best way to address these issues is to bring the care to these members. We recommend offering access to in-home care from physicians or mid-level clinicians. These providers can assume the role of the member’s primary care provider during the treatment period and coordinate with the member’s other providers to assure continuity of care.

On the other end of the spectrum, many members have minor health problems that can be easily resolved through a conversation with a physician and, perhaps, a routine prescription. For these kind of issues, we recommend that your members have access to providers telephonically, on-line or by interactive video. Most telehealth vendors can guarantee the wait time for a provider (usually under an hour) and integrate data with your plan’s system and the member’s primary care provider.

Demystifying approach: Think Differently about the way your members access providers. By providing alternative ways to access care, you’ll see higher member satisfaction, better health outcomes and much lower cost.

Following these five high impact recommendations now will go a long way in demystifying healthcare for your members while increasing compliance with care plans, improving outcomes and satisfaction and reducing costs. We are in a period of extreme change in healthcare and your plan’s ability to help your members navigate through these changes will be critical to your organization’s long-term growth and ultimate survival. It’s time to Think Differently.

At DeltaSigma, we have helped a number of health plans develop and implement successful approaches to adapt and thrive through the changing environment. We have also worked with vendors that offer the types of solutions described above. Let us know if we can be of any assistance as you steer your company into the future.

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