What every healthcare payer needs to know in order to implement accountable care and population health

1. Payers Must Reinvent Member
Experience to Manage
Accountable Care & Population
Health
paul@palerhinoconsulting.com
A remarkable experience for every person
every time (on any device)

2. Population Health & Accountable Care require payers to change
their member experience strategy.
• 80% of member interaction comes from 20% of its members
• The only interaction a payer has with the other 80% of its
members is a monthly bill
• Most members don’t know what additional services they have
and even fewer take advantage of those services
The impact of member experience on Payers
A remarkable experience for every person
every time (on any device)

3. To make accountable care and population health effective,
member experience strategy must be:
• Omni channel (phone, portal, social media, text, email)
• Interactive—from member to payer and from payer to
member
• Cognitive
• Employ mobile-first and design thinking
A remarkable experience for every person
every time (on any device)
The impact of member experience on Payers

4. The Payer business model must move from B2B to B2C.
• Customer service must become the dominant business
strategy
• The percentage of revenues from individuals will grow
dramatically
• The relative cost to serve a member will be significantly higher
• The number of member interactions will grow dramatically
• Member churn will increase
Payers will sell, deliver, and support individual policies that more closely
resemble the wireless industry (long-term contracts).
The impact of member experience on Payers
A remarkable experience for every person
every time (on any device)

5. The Payer business model and customer experience strategy is
not prepared to move from B2B to B2C.
• Taking care of members will be the competitive advantage
• Individuals will choose their payer
• Members will change payers
• Exceeding member experiences must become a business
imperative
The impact of member experience on Payers
A remarkable experience for every person
every time (on any device)

6. Payers’ systems and processes are not designed to effectively
support significantly more individual members with:
• eCare
• eCommerce
• Mobile channels
• Customer portals
• Call centers/CRM
• Business development, Sales & Marketing
• Payment & Collections
• Claims & Disputes
The impact of member experience on Payers
A remarkable experience for every person
every time (on any device)

7. What payers know about individual members:
• The treatment or procedure for which a member submitted claims
• The medications a member received
• Health history
• Whether the member paid their bill
What payers know from the combined analytics of all of their
members:
• Big Data only reflects the combined health data of all members
• Analytics forecasts the likelihood of segments of the population to
develop certain conditions
• Analytics forecasts health trends
The impact of member experience on Payers
A remarkable experience for every person
every time (on any device)

8. What payers don’t know about individual members:
• Whether the member’s treatment or procedure was effective
• Whether the member took their medication and adhered to it
• The health of a member who has not filed a claim
• The lifestyle of the member
• The current health and wellness of the member
Knowing how someone was does not reflect how someone is.
The impact of member experience on Payers
A remarkable experience for every person
every time (on any device)

9. To improve accountable care, population health, and Star
ratings, payers must:
• Improve member access to improve engagement
• Provide a remarkable user experience that is available every
time, at any time, and on any device
• Capture, monitor, and assess health data that reflects a
member’s current health
• Design an engagement platform across multiple channels that
is available 24 x 7, is two-way, and is cognitive
The impact of member experience on Payers
A remarkable experience for every person
every time (on any device)

10. Payers must design strategies, processes, and systems to
improve care and wellness.
• Assess which strategies, processes and systems will be
impacted
• How will this impact a Payer’s digital strategy?
• How will this impact a Payer’s mobile strategy?
• How will this impact a Payer’s call centers and CRM?
What Should Payers be doing now to be ready?
A remarkable experience for every person
every time (on any device)

11. The following slide depicts a high-level approach to recasting
consumerism, access, and engagement.
How We Approach Recasting Consumerism
A remarkable experience for every person
every time (on any device)

12. 3 Steps To Innovate Consumerism, Access, &
Engagement
Define Enterprise-Wide
Access/Experience
Strategy
Implement Interactive
Digital Access
Implement Effective
Voice Access
Create and implement an omni-channel (voice & digital) access and
engagement strategy using user-centered-design
• Understand how
stakeholders access &
engage today
• Meet with executives and
their stakeholders to
define their requirements
• Create stakeholder
personas & journey maps
• Define a vision for access
and experience
• Define the access &
engagement GAP
• Create the roadmap for
change
• Assess the digital
effectiveness
• Assess the benefits of an
interactive and cognitive
digital, mobile-first, and
social media strategy
• Evaluate creating a
consumer portal in
addition to the patient
portal
• Evaluate the findings
• Define an implementation
roadmap
• Implement the roadmap
• Assess the effectiveness
of the call center(s)
• Recommend what can be
improved & the process
and technology that
should be included
• Evaluate the value of the
recommendations
• Define an implementation
roadmap
• Use user-centered-design
to design a more effective
call center experience
• Implement the findings