The DNA of Healthcare

How Data Enables Payers to Improve Member Access and Experience

A female doctor sits at her desk and chats to an elderly female patient while looking at her  test results
Senior Vertical Solutions Consultant, Provider Data

Consumer experience and access to care are set to become major focal points for payers. The federal government is preparing to implement more rigorous benchmarks for health plan quality ratings based increasingly on how members perceive their interactions with the healthcare system. For payers, this requires a shift in thinking about data.

Consider the highly competitive Medicare Advantage space. Analysis by McKinsey & Company shows that the steady growth of MA plans will only continue, pushing the number of lives covered by the program to 34 million by 2023.

The firm notes that changes to 2023 quality metrics will have a marked impact on MA plans, given the healthcare industry’s lack of success in improving consumer experience. Beginning 2023, 57 percent of overall Star Ratings — the measurement system used by the Centers for Medicare & Medicaid Services to determine health plan quality and incentives — will be based on the consumer experience, up from 32 percent in 2020.

Health plans that do not improve their consumer experience ratings stand to lose significant revenue. “To achieve high Star ratings — and more broadly drive growth — MA plans will need to adjust their mindsets from a focus on gap closure to a holistic view of the member experience,” the authors of the analysis concluded.
Simply put, payers must make the consumer experience a top priority to remain competitive. And successfully doing so depends on data.

The power and potential of data

Compared to providers, payers have been slow to make data a central part of their operations.
“Hospitals are all about data — clinical, administrative, and operational information are key to quality improvement and financial success. It’s more of a struggle to convince payers that the data is more than a commodity,” says Laura Long, Senior Vertical Solutions Consultant at LexisNexis Risk Solutions.

“Oftentimes, payers believe their own claims tell the whole story about their members,” she continues. “But they only know what they know, lacking insights into how their members move across the care continuum as well as what their competitors are doing. Focusing on their own networks could easily create gaps when a member goes out of network. Increased visibility informs more effective strategies.”

This siloed approach to information will be insufficient to the task ahead of health plans, where wider knowledge of members becomes integral to improving both access to and experience of healthcare.
“The industry needs to be able to create a view of member health based on not only medical claims but also the various factors — social determinants of health — that could potentially impact the ability of members to have access to care or fulfill their obligation as a patient and have the best outcome,” Long explains. “Many payers and healthcare IT vendors that support payers focus on closed claims where you know every single episode of a member’s journey across a period of time.”

Incomplete and lagging information can easily lead to gaps in care and other negative impacts on member experience.

“Medical claims will tell you that an individual has diabetes and receives dialysis, but perhaps it shows in month nine that dialysis was stopped. Why did that happen? Is it that a member moved networks and now has a different payer because of a job change? Or is it because that member has an interruption in care due to socioeconomic factors that a claim does not provide?” Long notes.

With information about members scattered across the healthcare ecosystem, payers can serve as a convener of data to design and deliver benefits that meet the evolving needs and expectations of healthcare consumers.

A new approach to defining quality

Payers need to keep quality in the perspective of healthcare consumers top of mind to stay compliant with federal policies and competitive in a crowded market. Access to deeper and wider data sets holds the key.

“Meeting consumer expectations means bringing information together from across the broader ecosystem,” Long emphasizes. “There are so many factors that determine quality. In truth, quality is in the eye of the beholder, the eye of the member. Quality varies from member to member. Consumers have their own motivations, and those motivations are shifting. That is the future — many more factors than just costs will influence how people perceive quality of care.”

In many ways, the pandemic shone a bright light on the services and experiences healthcare consumers have come to expect.

“Most consumers have come to expect telehealth as a standard of care. If they know that they can make a phone call first before going in-person, they’re choosing that route if they’re able. A member-centered strategy must understand the central importance of access to care for members with various levels of risk, from individuals with chronic diseases to healthy individuals,” says Long.

Beyond access to care, payers must also recognize that today’s consumers think about quality based on their individual circumstances.

“Consumers have become more educated on their choices within healthcare, looking at not only quality of care but also whether a provider has certain attributes — language, gender, age, etc. — to meet their own needs. While members generally still look for in-network providers because there’s certainly a cost implication instead of that, there are other things that are important to them,” Long adds.

Health plans that invest in knowing more about their members by leveraging data will have a leg up on their competition. They will be better equipped to deliver personalized experiences to their members, becoming less reactive and more responsive to emerging trends that will impact their bottom lines as consumer experience comes to impact their revenue more directly. Like other industries, payers must understand what motivates and drives consumer behavior to keep pace with innovation and change.

The DNA of Healthcare

At LexisNexis Risk Solutions, our goal is to provide the healthcare industry with insights and innovations to improve outcomes, grow market share, reduce fraud and increase compliance.

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