Healthcare Consumerism: The next wave of Health Payer Digital Platforms

It is an amazing experience to work with some of the leading healthcare payers in the world, including Aetna, Cigna, EmblemHealth, multiple Blue Cross Blue Shield organizations, and many others. However, at their core, although some payers have truly embraced consumerism among their members, most still view their members almost exclusively as patients.

In this article, I will attempt to make the case for healthcare payers to embrace consumerism and provide a high-level overview of the technology blueprint needed to achieve this.

While the debate between the nuances of the two terms is not entirely settled, it’s important for healthcare payers to realize that their members, at some point, play both roles. Hence, next generation healthcare digital platforms need to cater to both.

Here is the how the two terms differ. Patients receive care based on decisions made by providers, while consumers make informed choices about their care—both qualitative and financial.

Most current healthcare payer digital platforms are designed for patients. They are built for collecting and providing clinical information and benefits options for when you are sick. They currently offer little practical usability for consumers because they were never designed to be consumer platforms.

Most member portals display benefits, deductibles, claims paid on a patient's behalf, and other such data, none of which really provides any great value to a patient's or a consumer's health needs.

Such systems were built as B2B systems to process claims reimbursements and ensure that all the relevant stakeholders have the most accurate financially relevant data. 

However, this completely misses the fact that a vast majority of members are not patients. Most people are in consumer mode, where other influences besides clinical data are the drivers of overall health status. A lot of patients need to monitor clinical and biometric data daily, such as type 2 diabetics who monitor their glucose, or healthy adults that are looking for a way to track their weekly cardio workouts, metabolic rates, etc. This clinical data might hold significant value for an individual member. However, there is no incremental value in storing this information in an Electronic Health Record (EHR).

The payer digital platforms need to focus on these two distinct but complementary aspects: clinical patient data that is most useful to providers, along with a holistic approach to wellness that is most relevant to consumers.

  • Provider Interaction. Payers are requesting more clinical data from providers, while providers need claims data from the payers. For each party, the additional insight these datasets provide is critical to being able to manage new payment and care delivery models. Payers can greatly enhance their ability to better manage the cost of care for their members by running deep analytics on relevant the clinical data.
  • Consumer Interaction. Engage members by providing a range of services to support their holistic health and wellness needs—fitness, nutrition, education about how the health system works, social support and communities, and rewards and incentives that go along with participating in those activities. Improved consumer engagement has a direct effect on revenue and profitability per member.

Empowering Population Health Managers by Improving Payer-Provider Collaboration

Population Health Managers (PHMs) collect, organize, and analyze healthcare cost and quality data from multiple sources, including health plans, registries, care providers, government entities, and providers. They then present their findings to stakeholders. Their primary goal is to drive down the cost of care by preventing at-risk and chronic members from getting sicker. The consumer-facing platform must align consumer actions and behaviors with incentives and rewards to coordinate with population health managers.

Currently, wearable devices are predominantly used only by early adopters—young, healthy individuals who use wearables as a part of their lifestyle. What PHMs really need is to be able to collect data on the sicker population that significantly drives cost, and convert that data into provider-integrated care management models to derive value.

Convert IT Assets into a Competitive Advantage

With the right digital platform solutions, business systems can understand data—structured and unstructured, text-based or sensory—in context and meaning at astonishing speeds and volumes. There are various types of analytics an organization can run, depending on its specific needs:

  • Descriptive—Discover, Report, Analyze
  • Predictive—Predict, Decide, Act
  • Cognitive—Understand, Reason, Learn, Interact

Data Stores and Data Integration

The analytics infrastructure will likely comprise several different kinds of data store solutions that coexist with the velocity, variety, and complexity of the data types and use cases.

Data stores can be roughly classified as follows:

  • Data stores you possess: Customer records, transactional systems, predictive models, institutional expertise, operational systems.
  • Data stores outside your firewall: News, events, social media, weather, geospatial information
  • Data that’s streaming in at all times: Devices/Internet of Things (IoT), sensory data, images, video

When it comes to dealing with such large amounts of data, the data integration layer takes on a lot of significance as healthcare organizations build an expanded ecosystem of partners, dependencies, and relationships. Your analytics solutions need to include a robust data integration layer.

Health Analytics

Analytic methods are rapidly changing as we enter the era of real-time analytics, cross-industry predictive analytics, and advanced capabilities leveraging artificial intelligence (AI). These include dashboards and reporting, data mining, visualization and AI (natural language processing, machine learning, and cognitive computing).

Healthcare is fertile ground for AI and emerging advanced analytics technologies to help improve outcomes, cut costs, and increase engagement. It will be transformational for healthcare delivery. The powerful combination of the industry's data-driven evidentiary approach to medicine with AI will revolutionize medicine and the delivery of care.

AI is already being used to automate difficult and time-consuming tasks (like preauthorization) and help with diagnostic imaging interpretation. It is moving the industry closer to the vision of precision medicine with technology like IBM's Watson for oncology.

Focus on Consumer Engagement

Irrespective of your political leanings, the Affordable Care Act was another giant step towards healthcare consumerism. It has made it even more important for healthcare payers to improve their consumer engagement capabilities.

Healthcare payers need to leverage customer journey maps to the increase customer loyalty, and hence improve profitability. Organizations must build curated content that is accessible and engages consumers throughout their consumer journey. Consider the website as your starting point but also as the door to the rest of your organization. If the landing page is your digital front door, think of the design as the journey you want customers and patients to have with your organization’s services.

While many business process improvement projects focus on processes with complexity in internal roles (such as sales, marketing, operations, HR, and finance), few have specifically targeted customer roles and the processes they are following. This internal human complexity is commonly represented by multiple swim lanes that detail the activities of different roles for the duration of the process from beginning to end.

This certainly is valuable—seeing the work item from start to finish, even if different people must do different things on that work item. The customer, however, is often represented as just one swim lane. Yet customers react differently and need different handling. They often don't follow the standard process, and many interact through multiple channels at the same time while engaged in their process.

The single swim lane representation of the customer reduces all that variability to a single standard approach for all customers. There is no single view of the customer at all. It is no wonder that the customer experience will suffer if viewed in such narrow increments and, in many cases, with little variation by larger distinctions like customer segment, product type and geography, or by much more specific single-customer personalization factors.

It is very important to connect the inside-out process maps to the outside-in customer journey maps. This will allow you to figure out the gaps in your current capabilities and will allow to focus your investment in the right place.

Always Think Mobile-First, and Choose Feature Quality Over Quantity

Mobile apps are a must-have technology for any business looking to compete for customers and elevate its workforce. Previously a separate and isolated concern, mobility is becoming an embedded part of every application and digital product. As this is happening, the characteristics of mobile-first development—such as feature quality over quantity and a focus on digital experience and modern tooling—are becoming critical to an organization’s ability to delivery great consumer engagement on a regular basis.

Focus on building what’s important to your customers, and leverage the customer journey map for this. For instance, we have consistently found that customers highly value features such as out-of-pocket cost estimators, access to health records, post-care instructions and follow-up notifications, and the ability to find in-network providers and schedule appointments online. In most cases, these features require integrating data as well as operations from across systems and departments.

Call to Action!

The challenges of transforming to a value-based healthcare model, combined with a focus on healthcare consumerism, are driving many of our clients to streamline core business processes and enable seamless and secure information sharing. Prolifics delivers innovative solutions that solve the business and IT challenges impacting patients, payers, providers, and employers. Our healthcare experts have proven experience, skills, and knowledge in this highly complex industry, aligning innovative and proven solutions to solve our clients’ business goals.

Reach out to me, and we can talk about how Prolifics can help you on your Digital Journey!

About the Author


Prithvi Srinivasan
Global Head of Digital Experience and Hybrid Cloud Integration

Prithvi collaborates with clients to help them craft transformative enterprise strategies. He has led large and complex solution deployments for multiple customers across the financial services, banking, healthcare life sciences, retail and insurance industries.