From Reactive to Proactive

How a health plan can get ahead of regulatory changes

The question I have been asking myself in the wake of the regulatory changes and now the lawsuits in response is how we can become more nimble so that addressing challenges isn’t quite as painful. I am allergic to magical thinking and wanted to unearth some concrete steps we can take. I decided to talk to people who have spent a long time in the sector to see if I could glean some wisdom from their experiences. During my conversation with Linda Shoenfelt, a seasoned professional with a wealth of experience in the health insurance industry, we discussed some specific areas she sees as potential risk areas this year and how to build a solid framework so that changes become easier to manage.?

Linda Shoenfelt has held key roles as VP of Operations at Aetna, Coventry, HealthMarkets, Assurant, and Universal American. Her unique perspective, having worked on both the distributor and health plan sides, and her over twenty years of experience in Medicare, Medicaid, and other lines of life and health insurance make her a valuable source of insights.

Besides the sheer number of changes, why is it in general a challenge for plans to address regulatory changes?

Many health plans have grown through acquisition over the years and are operating with multiple vendors and internal disparate systems. Not only does this increase operating costs as they will need to “ready” each platform and process for the required changes, but it has resulted in challenges in capturing and sharing the pertinent level of customer-specific data and insights required to efficiently communicate the impacts and changes to the member and their experience in concrete ways.

How does having multiple systems and vendors affect member experience?

If a plan has yet to create a single source of truth for member data shared between its systems and vendor partners, it may not have the information needed to determine the complete picture of member impacts or communicate what those impacts mean to the member.

Why is relationship management so important this year??

This year's changes will require a paradigm shift in how plans market their extra benefits. This will affect how members choose a plan and will require communicating around the benefits they truly need and are likely to use if the plan has them. Preparing members for changes is critical to avoid complaints and abrasion.

Why is it hard for a plan to get ahead of member abrasion and complaints??

Well, I would like to start by explaining how health plans in the industry categorize calls and/or evaluate complaints (especially those reported directly to Medicare/CMS). Generally, they begin by looking for what “they” are responsible for doing/not doing correctly.? If they do not uncover an error or cause they can fix internally and/or explain to the member, the issue is often categorized as “out of their direct control.”? This is usually attributed to headwinds in the industry, such as changes in the marketplace, within the regulatory environment, or alternatively just a lack of “member understanding.”?

What would typically need to happen to see processes change to address member abrasion??

It is more important than ever to “tell” a member what is changing and to help them understand how it impacts them specifically. If plans don’t know their members well and tailor their communication and method,? they tend to use broad communication that may not apply the same way to each member's situation. Members can feel it (or not); hence, the disengagement begins, and the lack of preparedness and complaint/abrasion avoidance is thwarted.? If members are disconnected, it compromises loyalty. This year, more than ever, it will be crucial to help members adjust to changes and understand how they affect them.

Let’s get specific: how would understanding your members help you this year in responding to all of the the current changes?

Here are some that come to mind:

It would help identify the underserved, duals, disabled, LIS, or critically ill populations.

Sales and communication would benefit if they didn’t have to ask the same questions repeatedly.

We would be able to communicate with members explanations of Part D benefit changes due to pricing and formulary impacts.

Also, we would be able to communicate with members in ways that they understand individuals about MA benefit changes due to pricing, reimbursement, and other business impacts. This would also apply to OON cost sharing for SNPS and ANOCS.

We could provide members with explanations of supplemental benefits and their cost/benefit structure.

It would help brokers sell what is genuinely needed and used vs. a perk that may come at a new cost)

It would allow a plan to identify and communicate with those impacted by behavioral network facility category changes.

If we want to respond more effectively to these specific regulatory changes, we need a solid foundation where systems speak to each other. Investing in understanding our members prevents member confusion and improves communication, which leads to less member abrasion.

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TLDR: The regulatory changes in the market will affect members, and we know that change often results in dissatisfaction. If we want to avoid member complaints and abrasion, we need a strategy to ensure that we know our members well so that we know how to communicate with them and how to avoid complaints.?