How health plans can improve the member experience through consumed data

Not surprisingly, many health plans are quickly updating their models to improve provider data inaccuracies, enable members to find the right care, and avoid costly penalties for inaccurate data. are compatible. With ghost networks in the headlines recently and inaccurate data impacting patients’ ability to find care, health plans across the country must act quickly to rethink their current data solutions to improve the patient experience. members and to save costs through automation.

In 2017, the Centers for Medicare & Medicaid Services (CMS) conducted a study of online provider directories and found that 46% of locations examined had inaccurate information resulting in a lack of access to care. Despite inaccurate data being a major culprit in patients’ ability to find care, patients still trust health plans to provide accurate information to help them identify the right provider, according to the Health Plan Study of To JD Power US Merchant Members 2021.

So what does this mean for health plans? Health plans have an opportunity to revamp their current data infrastructure to not only update provider data in real time, but improve the provider search experience to increase member retention and satisfaction and ultimately help patients find better care.

The way to achieve this ultimate goal is to consume data. Consumed data, in the case of health plans, would include retargeting current products and services to model similar consumer experiences, think about online shopping, for members. In short, health plan provider networks should display detailed information about providers that allow each user to personalize their care decisions. In this article, I examine several ways health plans can turn to this solution with their existing data. This approach, if done correctly, can help health plans provide more customer-centric services that help patients find differentiated, high-quality care that meets their specific needs.

Single source of truth for data from multiple sources

More data does not necessarily mean accurate data or better patient experiences. It’s what health plans do with that data that drives member retention and acquisition. Health plans should see the gaps in their current data as a driving point to improve their current infrastructure and pull in diverse data outside of traditional provider sources. This can help health plans position their provider search platforms as the single source of truth for provider information across a variety of data points. For this to happen, health plans must leverage rich, external data networks to pull in a variety of provider data beyond phone numbers, email, and addresses.

Because consumers know that health plan provider directories are not always accurate, they seek information from many other sources such as search engines, doctor rating sites and social media. The rise of ghost networks and outdated provider records has created a frustrating experience for members and can result in additional costs for health plans if a member goes to a provider that is actually out of network and undergoes unnecessary procedures and services and costly. Instead, data must be validated, synthesized, and distributed from payer to member in a clear format to help members make confident decisions about their care provider.

The rise of telehealth is a relatively new factor, but also a critical one to consider. Virtual care visits are cost-effective for members, providers and health plans. An analysis conducted by McKinsey & Company in May 2020 suggested that providing virtual emergency care assistance could cut emergency room visits by 20%. Including information such as virtual care availability and improving the comprehensiveness of a health plan’s provider directory can position that directory as the single source of truth. This reduces the friction and frustration that members experience when they have to search through multiple sources to determine if a doctor actually takes their insurance or actually treats knee joint pain instead of back pain.

Using machine learning to drive actionable data

Machine learning can be a health plan’s secret weapon when it comes to consuming existing data. Health plans can improve their provider information by pulling data from outside sources – there is also a clear opportunity for plans to use this data to arm consumers with more personalized provider options.

In addition to phone numbers and addresses, health plans should expand their provider data to include considerations such as cultural backgrounds, languages ​​spoken, specialties and focus areas of expertise, and quality indicators. Health plans should also look to optimize their current provider search experience to allow patients to direct their provider search with personalized filters that include ratings and social/cultural parameters.

For example, if I’m looking for a provider that specifically treats joint pain, is located in Idaho, has 4.5 star reviews from other patients, and can speak Spanish, I might have a challenge finding that one exclusively. through my current health plan provider data. However, if this health plan used data informed by machine learning, I could experience a much smoother and more accurate search experience.

Machine learning models would analyze thousands of search results and predict that Dr. Camila Velasquez, who practices at 41 Broadway, is the same provider as Dr. Camila Velasquez-Smith who practices at 41 W Broadway and also no longer practices at 66 Main Street. Instead of seeing 20 similar results for the same person, I’m provided with an accurate and consolidated list that has the information I’m looking for. The machine learning would also recognize the many terms and specialty focus areas that can be categorized as “joint pain” and pull those results to make sure I’m seeing all the available options.

The results I get from a provider search powered by machine learning are personalized, centralized, and filtered to meet my quality expectations. As a patient, this saves me time, frustration, and ensures that I am directed to the right provider for my specific needs.

Enriching existing provider data to enable members to make personalized care decisions

Data is not enough if it is not personalized. Health plans can increase credibility and trust with members by offering personalized provider searches like the example I shared above. With enriched provider data, health plans can provide members with more information that is personally relevant to their care seeking, thereby improving member retention and increasing their market share through enhanced health care experiences. to the members.

The opportunity to innovate here is only growing for health plans. According to the JD Power 2021 US Health Plan Member Health Plan Study, only 22% of members said their health plans are “innovative,” citing the need to improve digital channels for better customer engagement.

Research shows that when members see health care providers who share their cultural background, speak the same language, or reflect their experiences, their health care outcomes improve. Some states have taken a proactive approach to getting health plans to collect and share this information with members.

Colorado, in particular, passed the Colorado Choices Rule on March 2, 2022, which requires health plans to collect demographic information, such as race, ethnicity, disability status, sexual orientation, and gender identity, from both health professionals and from registrants to improve members. and provider compliance. This type of information is essential to enable data consumption and provide patients with an experience centered around their quality standards to identify the right provider.


Ultimately, health plans and members have the same goal: seamless navigation to the correct, in-network provider that best serves the member’s needs.

The current structure of health plan provider searches should not be the standard. Rapid consumerization in other industries has given health plans a model for using today’s technology to personalize the patient experience. Patients are the ultimate winners as health plans aim to make this difference. For the first time, we can begin to see the network effects of empowering patients with accurate, enriched provider data to facilitate more appropriate, cost-effective, high-quality healthcare decisions.

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