Taking an honest look at our members' pain points: Part II

To provide an honest look into how we are serving our members, I’m going to use today’s post to share the top pain points our members face, and what they teach us about the healthcare system.*

As I said in my last post, our goal with this analysis is to create transparency into the areas where we’re falling short in our mission to make healthcare easier. We’re doing this because we care deeply about our members. We spend a lot of time trying to understand their issues and develop solutions for their problems, and we’re accountable to making healthcare easier for them.

Below are our members’ top 10 pain points by volume for 2019.

Top-10 pain points by volume, 2019

Many of these issues stem from problems that the overall U.S. healthcare system has, and which we’re committed to fixing - but which in these cases we haven’t satisfactorily solved.

• U.S. healthcare is too expensive. Right at the top, members complain about deductibles being too high, which is just another expression of the high costs in our healthcare system.
• Those high prices lead to complicated cost-sharing, which in turn leads to member issues with understanding it. Here, we either didn’t explain well how cost-sharing works in a particular situation. Or the complexities of the system created an unexpected surprise cost-sharing for members, and we weren’t out in front of that to keep it from happening.
• Or the gates that we put up to manage the high U.S. healthcare costs get in the way (e.g., members complaining about prior authorization requirements).

These issues drive our general strategy as a company.

• We know that U.S. healthcare is way too expensive. So our highest goal is to create more affordable healthcare for our members, and we constantly try to find all kinds of ways to do that (including things like free virtual urgent care and our $3 drug tier that we launched this year).
• We look for ways to actually reduce the complexity of the healthcare system by doing things like introducing one of the first no-deductible bronze plans in the country this year, or by tracking in real time billing issues with providers, and making those issues transparent in our care router. 
• Where we can’t eliminate the complexity, we strive to educate members better than any other company on how healthcare works and to communicate complicated cost-sharing in simple, understandable terms.

Moving beyond the top-10 of member pain points, five main areas dominate the member issues we saw in 2019.

Cost: Healthcare costs are high, and they continue to rise at an alarming rate. Surprise billing, outdated financing practices and disjointed payment systems add complication to the system. We categorize issues related to the overall high cost of the system and getting the most value for services, understanding claims and costs post-service, and paying monthly premiums, co-pays, or other out-of-pocket costs in this bucket.

Network: Many studies of U.S. healthcare show that there is virtually no correlation between the cost and the quality of providers: meaning, more expensive providers don’t deliver better care than more affordable providers. (Here is a recent one in Health Affairs on physician cost vs. quality, and here is a recent one that shows little improvement in quality for large increases in hospital costs.) Since Oscar’s early days, this has meant that we build more focused provider networks, and can get more affordable pricing with better providers for our members. That makes it even more important to help our members find the right doctor at the right time. This category of pain points capture those situations where that didn’t work as well as it should have. So, members may feel a pain point when navigating our selective network, don’t understand how to use Oscar’s network and related partners, or want to see a particular provider who isn’t part of the network.

Care: The healthcare system is fragmented, and we see Oscar as the member’s advocate to help navigate the system and to remove complexity. But issues may occur when members don’t have the information they need to navigate the fragmented health care system and make educated decisions that weigh cost vs quality. This includes members not having an understanding of costs prior to using services, running into issues getting care authorized, and not knowing how to get the most value out of their given plan and for their unique health needs.

Onboarding: This includes concerns from Oscar members struggling to understand their benefit options or having issues related to affording care. Specific pain points included here are issues related to signing up for an Oscar plan and related channel options, making plan changes post-enrollment, or delays or misinformation around the overall onboarding process. At a high level, some of these represent strange corners the healthcare system has backed itself into. For example, why do insurers really have annual deductibles, based on calendar years, which is unfair to many people? Mostly just because that’s the way it’s always been, and because it’s easier for the existing system - not the members.

Benefits: Member pain points in this category include concerns about not understanding what’s covered within the benefits of various plans and why. These issues include understanding preventive vs diagnostic benefits, benefit limitations or exclusions, or exhausted benefits, or benefit formularies and options vs costs associated with prescriptions, vendors, labs, etc.

I’ll be dedicating a post to each of these areas over the coming weeks, and will be including a more detailed description of what is causing our members concerns and how we plan to address them.

*These categories are for Oscar’s internal use only.