The Evolving Regulatory Landscape & The Member Experience: Key Learnings and Insights

Earlier this year, a select group of clinical leaders from across the country gathered with HealthEdge and Wellframe at the Clinical Leadership Forum, an event that provided a unique opportunity for thought leadership, in-person connection, and learning. Through the lens of leveraging care management as a catalyst for digital transformation, sessions focused on strategy, regulatory compliance, innovative technology, value-based care, member engagement, and more.

Of particular interest to attendees was the growing connection between regulatory compliance and the member experience – a topic that spurred thought-provoking conversation and discussion. Today, this topic continues to hold relevance for health plans as an increasing number of regulations emphasize the member experience.

Here, we summarize key learnings and takeaways from the session, “Quality Insights & Regulatory Update,” which covered evolving regulatory changes and the increasing influence of health equity and member experience as factors for achieving compliance. The session presenters, clinical experts from HealthEdge, also discussed how health plans can prepare and support compliance in the rapidly changing landscape.

Let’s dive into the key learnings and takeaways from this informative session.

The Importance of Member Engagement Reaches New Heights

While member engagement has long been recognized as crucial, it has now reached unprecedented importance. The COVID-19 pandemic highlighted existing health disparities and underscored the need for enhanced member engagement to address the challenge. Health disparities are preventable and new regulations aim to put better measures in place to improve engagement of priority populations and advance health outcomes where disparities exist today.

Changes in Regulatory Measures

The presenters discussed the Centers for Medicare & Medicaid Services’ (CMS) proposed changes set for December 2024 that target improvements in member engagement and health equity, which ties member satisfaction closely with outcomes. Proposed changes include:

  • Reducing the weight of patient experience to better align with outcomes.
  • Identifying and offering health education to improve digital health literacy.
  • Improving language accessibility by delivering materials in all languages spoken by members.
  • Delivering culturally competent care to better support diverse populations.
  • Changing and enhancing calculations to better align with other programs.

The presenters also covered updates to HEDIS measures to better support diverse and underserved populations and improve their engagement.

A New Trend in Regulatory Changes: Member Engagement

The presenters pointed to an underlying theme across many new regulatory changes: increased focus on member engagement. As a result, optimizing the member experience and engagement is becoming even more of a top priority for health plans. To deliver on this priority, health plans should evaluate how they are supporting members needs in five key areas:

  1. Multiple channels of communication: Health plans should work to understand how their members want to communicate and strive to offer those methods. Offering the right methods of communication is the first step to ensuring members receive the information they need to better manage their care.
  2. Strategic outreach & follow-up: Intentional follow-up to build relationships or outreach after appointments and procedures can improve engagement.
  3. Streamlined member service experience: Health plan leaders should know customer service call stats and hold times, listen to calls to understand if issues are truly being resolved, and find out how customer service teams are engaging with members. Deeper knowledge of the real customer experience allows health plan leaders to assess and make improvements as needed.
  4. Identify unengaged members and activate campaigns to re-engage: Gather data to holistically understand the member experience and identify unengaged members. Using claims data, encounter data, failed outreach attempts, and more gives health plans the opportunity to assess whether members are taking steps needed to effectively manage their health.
  5. Understand the impact of member experience on outcomes: Health plans should consider conducting surveys to understand the member experience and make improvements. Also, consider the value of annual wellness visits and regular appointments, as members who are getting next level care through mammograms, lab testing, colonoscopies, and more can take steps to manage their health concerns as needed – and have a significant impact on outcomes.

Partner Expectations: Using Technology to Advance Member Engagement

The right technology partner can support health plans in their journey toward improving member engagement and outcomes tied to regulatory compliance. Seek care management partners that deliver the following capabilities:

Robust reporting: Ensure reporting capabilities can facilitate quality improvement projects and demonstrate that the plan is improving member health. Effective reporting should allow health plans to identify unengaged members, get them engaged, and keep them engaged.

Member demographics: Ensure the system can capture key data points, report out, and stratify that data. Key demographics include geographic location, gender identify, race, ethnicity, and more.

Detailed HRAs that drive Plan of Care & Service Plan: Use technology with capabilities to enter surveys, get members responses, and capture data. The technology should allow care managers to use the data to ensure the care plan is specifically targeted based on information collected.

Real time referrals to Social Determinants of Health (SDoH) providers: Implement full integration with social care providers to enable care managers to better manage all individualized member needs.

Care gap monitoring and closure: Use technology that identifies care gaps and supports methods to intervene and drive closure.

Programs identification and management: Seek partners with capabilities that automatically identify members for complex and disease management programs through self-reported or automated data collection. Ensure the technology uses the data to assign members to the right care coordinator to ease the process of improving engagement for high-risk populations.

Integrated educational content: Implement technology with the ability to deliver clinically sound, evidence-based data through effective communication channels. This capability is critical to combat misinformation and improve care outcomes.

Interdisciplinary team management: Deliver tools, such a provider portal, to allow the full team to understand member needs, see their goals, talk to members about those goals and help work towards achieving them.

Take the Next Steps Toward Supporting Regulatory Compliance and Member Engagement

By promoting health literacy, addressing disparities, and prioritizing member engagement, health plans can navigate the shifting regulatory landscape. Collaborating with the right partners and leveraging modern technological capabilities allows health plans to deliver high-quality, equitable care and achieve positive health outcomes.

Learn how GuidingCare and Wellframe from HealthEdge can help health plans achieve these goals by visiting


3 Main Benefits of Value-Based Care Software and How it is Revolutionizing the Health Insurance Industry

In an era where healthcare costs continue to rise, the concept of value-based care has emerged as a game-changer in the health insurance industry. Value-based care focuses on achieving better patient outcomes while reducing costs and improving the member experience.

To effectively implement and manage value-based care contracts, modern software solutions have become essential. In this blog post, we will explore how value-based care software is transforming the health insurance landscape and optimizing outcomes for patients, providers, and payers.

Understanding Value-Based Care

Value-based care is a departure from the traditional fee-for-service model, where providers are reimbursed based on the volume of services rendered. Instead, value-based care focuses on aligning incentives between payers and providers to promote quality care, patient satisfaction, and cost-effectiveness. Contracts are structured around outcomes, quality metrics, and patient satisfaction.

The Challenges of Implementing Value-Based Care Contracts

While the concept of value-based care is promising, its implementation poses significant challenges for health plans. Tracking and analyzing vast amounts of data from multiple sources, calculating reimbursements based on outcomes, and ensuring accurate reporting require sophisticated software solutions that can handle complex computations and streamline processes.

Value-based care software solutions, like those from HealthEdge, play a pivotal role in successfully implementing and managing value-based care contracts. These modern solutions offer a range of features and functionalities that optimize the healthcare ecosystem:

Data Aggregation and Analysis

Value-based care software solutions facilitate the aggregation of data from various sources, such as electronic health records, claims data, and social service providers. Advanced analytics capabilities allow for the extraction of valuable insights, identifying patterns, and predicting member outcomes. These insights drive informed decision-making, enabling health plans to determine which members may be at risk for developing costly complications and need more personal, proactive care.

Care Coordination and Communication

Value-based care software can enable more seamless collaboration and communication among care teams, members, and payers. Real-time updates, shared care plans, and secure messaging platforms ensure effective coordination and enhanced member engagement. By fostering continuity of care and reducing duplication of services, value-based care software optimizes patient outcomes while minimizing costs.

Performance Monitoring and Reporting

To ensure accountability and adherence to quality standards, modern value-based care software solutions enable continuous performance monitoring and reporting. Payers can monitor network performance, measure the effectiveness of interventions, and drive network optimization strategies. Providers can track their performance against established quality metrics, identify areas for improvement, and proactively address gaps in care.

Benefits of Value-Based Care Software

Implementing value-based care software offers numerous benefits to all stakeholders involved:

  1. Improved Member Outcomes: By leveraging real-time data and analytics, value-based care software empowers health plans to deliver personalized care plans, preventive interventions, and evidence-based treatments. Members receive more comprehensive, proactive, and coordinated care, resulting in improved health outcomes and enhanced member satisfaction.
  2. Cost Savings and Efficiency: Value-based care software streamlines administrative processes, reduces paperwork, and automates tasks, enabling care managers to allocate more time and resources to at-risk and rising-risk members. By promoting preventive care and early intervention, costly complications can be minimized, leading to significant cost savings for payers and patients alike.
  3. Enhanced Provider-Payer Collaboration: Value-based care software promotes collaboration between providers and payers, fostering a shared commitment to delivering quality care. Through transparent data sharing, real-time performance feedback, and aligned incentives, providers and payers can work together to optimize care delivery, drive population health management, and negotiate mutually beneficial contracts.

Driving Value Through Value-Based Care Software

As the health insurance industry continues to evolve, so will the ways in which health plans create and manage their value-based care contracts. Value-based care software empowers stakeholders to harness the power of data, streamline processes, and foster collaboration, ultimately revolutionizing the healthcare ecosystem. By embracing value-based care software, the health insurance industry can unlock the full potential of value-based care, leading to better patient outcomes, increased cost savings, and better member experiences in the future.

At HealthEdge, our full suite of software solutions supports our customers’ efforts to embrace value-based care contracts in many ways, including:

  • GuidingCare® care management solutions that help health plans coordinate and manage care for members more effectively. These solutions include care coordination tools, population health management tools, and analytics to identify high-risk members and deliver more personalized care plans for better health outcomes.
  • HealthRules® Payer, an advanced Core Administrative Processing System (CAPS), supports health plans’ ability to manage multiple, complex payment models with the efficiency, flexibility, insights, and agility necessary to control costs, embrace change, and move quickly to take advantage of new opportunities value-based care models afford.
  • Source, HealthEdge’s prospective payment integrity platform, includes rich editing libraries with history-based capabilities and enables easy development of customized edits, improved transparency, and reduced downstream work from inaccurate payments, which leads to better provider and member relations.
  • Member Engagement: HealthEdge’s Wellframe solution enhances member engagement and empowerment. This may involve mobile apps or member portals that enable patients to access their health information, schedule appointments, receive reminders, and communicate with their care team.
  • Data Analytics: All HealthEdge solutions incorporate advanced data analytics’ capabilities that help health plans gain actionable insights from virtually any data source, identify cost-effective treatment options, assess provider performance, and optimize care delivery.
  • Integration and Interoperability: Seamless data exchange and interoperability are critical in value-based care. HealthEdge solutions aim to integrate with various electronic health record (EHR) systems, health information exchanges (HIEs), and other healthcare applications to ensure smooth data flow and better care coordination.

To learn more about how HealthEdge value-based care software solutions can help your organization thrive in a value-based care world, visit

The Changing Landscape of Star Ratings: Challenges Ahead for Payers

Star ratings have long been a cornerstone of assessing the quality and performance of health insurance plans from the Centers for Medicare & Medicaid Services (CMS). These ratings play a crucial role in helping beneficiaries make informed decisions about their healthcare options. For payers, Star ratings bring incentives to improve their services and member outcomes to achieve higher ratings.

However, recent developments in the Star ratings program are set to bring about significant challenges for many payers.

One of the most notable changes is the introduction of a health equity index in 2027. Social risk factors, such as income, education, housing, and access to transportation, can significantly impact individuals’ health outcomes. The health equity index aims to evaluate how well health plans are addressing these factors and working towards reducing health disparities among their beneficiaries. However, this presents signification challenges for payers:

  • Data Collection and Standardization: Assessing social risk factors requires reliable and comprehensive data. Payers will need to collect and analyze data from various sources to accurately evaluate their performance. Standardizing the data collection process across different plans and regions may also prove to be a complex task.
  • Resource Allocation: Addressing social risk factors often involves implementing community-based programs, outreach initiatives, and partnerships with social service organizations. Payers will need to allocate resources effectively to support these efforts while balancing their financial viability and sustainability.
  • Collaborative Approach: Tackling social determinants of health (SDoH) requires collaboration among multiple stakeholders, including healthcare providers, community organizations, and government agencies. Payers must foster partnerships and cooperation to drive meaningful change in social risk factors, which may require navigating complex networks and overcoming potential resistance.
  • Long-Term Impact Measurement: Evaluating the impact of interventions targeting social risk factors requires a long-term perspective. Changes in health outcomes may not be immediately evident, requiring payers to invest in ongoing monitoring and assessment to accurately gauge the effectiveness of their efforts.
  • Addressing Inequities: The health equity index aims to reduce disparities in health outcomes among beneficiaries. However, payers may encounter challenges in identifying and addressing specific inequities within their member populations, as these disparities are influenced by a range of complex and interconnected factors.

Other proposed changes to Star ratings:

  • Limited Application of the “Better of” Methodology: In response to the COVID-19 pandemic, CMS allowed all contracts to use the existing disaster provision in 2022. This provision enabled contracts to choose the “better of” current or historical performance for most measures. However, in 2023, this methodology will no longer apply universally.
  • Implementation of Upper and Lower Limits (Guardrails): Starting in 2023, CMS will implement annual guardrails on changes in cut points for non-CAHPS measures. Cut points define the ranges within which a contract’s score on a specific measure needs to fall to achieve each Star value. These guardrails will introduce more challenging cut points, potentially impacting the ratings of MA plans.
  • Removal of Performance Outliers: In 2024, CMS will use the Tukey outlier deletion method to remove performance outliers from the calculation of non-CAHPS measure rating cut points. This change aims to enhance the accuracy of the ratings but may pose additional challenges for MA plans.

To mitigate negative impacts, Medicare Advantage plans must turn to modern care management systems that support the growing complexities of performance measurement programs. Payers should embrace these challenges and use them as opportunities for growth and improvement. The journey towards achieving higher Star ratings and ensuring equitable healthcare requires dedication, innovation, and a deep understanding of the diverse needs of the communities they serve.

To learn more about how HealthEdge’s GuidingCare care management solution suite can help your organization address the growing challenges associated with Star ratings, visit

Leveraging Privacy to Build Trust

Good privacy practices have become a valuable business asset that produces a myriad of benefits.

Processing data and protecting data are fundamental components of today’s digital economy, generating extraordinary value and catastrophic risk across the globe. Fueled by the increasing number of large-scale and well-publicized data breaches and a growing privacy awareness, individuals and businesses are becoming more discerning about the parties with whom they choose to do business. In addition to the quality of a business’s products or services, individuals want to know how companies incorporate privacy into their operations and want assurances that their personal information will be treated with the utmost care and respect. Individuals are more likely to share their information with companies they know will keep their data safe, making trust an essential component of the information exchange between individuals and the companies with whom they choose to do business.

The risk of harm to an individual from the loss or exposure of personal information is particularly apparent in healthcare due to the sensitive nature of the information involved. Medical records, test results, and other types of protected health information (PHI) hold an incredible amount of private data that could cause extraordinary harm or embarrassment if exposed or stolen. Protecting the privacy of high-risk information requires a proactive and multi-faceted approach and companies must implement strong privacy and security measures to safeguard PHI from unauthorized access, use, or disclosure.  The sprawl of digital data compounds the innate challenges that come with the responsibility of safeguarding personal information. Privacy regulations, like the Health Insurance Portability and Accountability Act (HIPAA), have requirements that can be time-consuming and complex. Administrative safeguards, such as access controls, can hinder operational ease due to limitations on employees who can access PHI. However, in the digitized healthcare industry, the preservation of privacy is paramount.

At HealthEdge, we value privacy and utilize an integrated approach to ensure that the information entrusted to us remains protected and secure.

Privacy + Security

While privacy focuses on the appropriate and permissible handling of data, security is responsible for implementing technological measures and safeguards that actively protect data from unauthorized access, loss, or exposure. At HealthEdge, the Privacy and Security teams work together in a dynamic and collaborative partnership to instill good privacy practices and security safeguards throughout the enterprise.  Implementing robust security measures that align with broader privacy principles like data integrity provides a layered data protection approach that effectively mitigates areas of increased risk.

Comprehensive Risk Assessments

Comprehensive risk management should incorporate privacy assessments to properly identify and mitigate risks to an enterprise. Risk assessments are a commonly used risk management process for identifying and evaluating the likelihood, vulnerability, threat, and impact of identified risks throughout a company’s operations. Enterprise-wide privacy risk assessments can help businesses identify overlooked vulnerabilities, encourage opportunities for collaborative decision-making, spur creative innovation in the development of new data protection solutions, and increase employees’ privacy awareness.

Minimum Necessary Standard

Companies with strong privacy programs recognize the heightened risks that sensitive data carries and implement a variety of safeguards to ensure their data is adequately protected. By prioritizing privacy, businesses can demonstrate their commitment to protecting personal information while also mitigating the risk of security incidents and data breaches.  At HealthEdge, we enforce the minimum necessary standard for our data processing activities. The minimum necessary standard is a data minimization requirement under HIPAA and a fundamental privacy principle meaning only the minimum necessary data should be used to accomplish the intended business purpose. By minimizing the collection and use of personal information, companies can demonstrate their commitment to protecting personal information and reduce the risk of processing a surplus of information.

The Value of Good Privacy

Companies should have a firm understanding of these fundamental privacy practices, a cross-functional approach to data protection efforts, and the ability to recognize and adapt to the evolving (and expanding) privacy preferences of customers who are looking for businesses they can trust. The successful evolution of a company’s privacy program into a full Privacy by Design (PbD) framework is largely dependent on receiving intradepartmental and leadership support, but support for driving privacy initiatives forward can be a challenge. Stakeholders should know the necessity of privacy in today’s environment and understand how it can be leveraged as a competitive differentiator that builds trust. Aligning privacy goals with core business objectives can influence business decisions and help ensure that privacy is prioritized and supported. A trustworthy reputation is an asset that can generate economic value, attract new customers, and fortify a company’s ability to withstand challenging incidents.

At HealthEdge, we understand the vital role that privacy plays in securing customer trust and embodying good data stewardship. By prioritizing privacy, the data that is shared with us is kept confidential and secure.


The Powerful Dividends of Focusing on Employee Experience 

A robust and thriving employee experience boasts happy and loyal customers, high performing teams, and a work environment that exudes flexibility and purpose. A well curated employee experience captivates great talent and makes them want to stay. Powerful dividends like these cannot be ignored and employers must pay attention to ensure they maintain the competitive positioning of having the best talent serve their customers.

At HealthEdge, we have been committed to our employees for years. Years before the pandemic, we focused on employee engagement. Through annual surveys, we would tap into the employee voice and digest the results collectively focusing on how we can learn and grow and ultimately improve together. This has become the foundation of our approach to employee experience.   Since the pandemic, many forces have changed our approach to achieving the same end state. Internally, HealthEdge has grown organically and inorganically, we have acquired and welcomed new products into our product suite and constantly seek ways to fulfill our vision of innovating a world where healthcare can focus on people. Externally, we lived through drastic shifts that have left many lasting effects on the way we live and work. To continue to approach employee engagement the same way we had through all that change felt shortsighted and I am proud of how we stayed curious and flexible. This work is never done but with employee experience as our north star, creating something intentional with our company culture has renewed vigor.

If you are interested in doing this too, we recommend building your employee experience model around the following:

  1. Purpose

Employees want to know about your purpose. They want to feel like they’re a part of something bigger than themselves. A powerful, compelling purpose and why is critical to employee engagement in their work and connection to those around them. We want our employees to be excited about how we’re shaping the future of healthcare. Therefore, it is our responsibility to tell that story, over and over.  You know the story and principles have sunk in when they begin telling others.  Find your company’s purpose and make sure it is persuasive and inspiring, then tell everyone, and then tell them again.

  1. Enablement

Enablement is a reflection of whether an employee has what they believe they need to do their job well. Fundamentally, this is highly subjective territory. I am not advising you to please everyone, but asking staff about their perspectives equips you with insights into their expectations.  This is about recognizing themes and solving for the collective. More than anything it is about listening to your staff and ensuring they feel heard.  Enablement goes beyond tools and resources used to do the mechanics of the job. It encompasses collaboration, community, and camaraderie as well. At HealthEdge, among other things, this dialogue and feedback has led us to streamline our digital collaboration tools as well as how we collaborate in person within our hybrid work environment.  We are always working to improve how we purposely gather during our monthly collaboration weeks. Talk to your employees about enablement, community, and collaboration topics because these are unspoken pillars that are critical to keeping employees engaged.

  1. Autonomy

Autonomy means setting the vision and empowering your employees to make it happen. It means trusting your employees and enabling them to make decisions. For years, we have been inspired by the work of Daniel Pink who coined “autonomy, mastery, and purpose” as the fundamental factors that DRIVE employees. Granting autonomy can manifest in many ways. It can be finding ways to support remote or hybrid work based on the asynchronous workflows. It can be evaluating how much oversight managers and leaders provide vs allowing your teams space to exercise new skills. With autonomy, employees can harness the power of maximizing their personal productivity, creativity, and flow. Autonomy is highly reflective work and leads to greater ownership over the work. As you get started, talk to your teams about small ways that would have big impacts.

  1. Rewards & Recognition

Rewarding and recognizing talent are paramount to employee experience. Rewards are tangible and transactional in nature: salary, benefits, PTO, holidays, etc. Regardless of the offerings you have available, it is paramount that your process for rewarding is consistent, fair, and equitable. Our approach to rewards at HealthEdge is merit based, meaning they are intrinsically connected to recognition of a job well done. In 2022, we added 4 extra company holidays in the summer – this created four 4-day weekends in the US, putting our values of encouraging our employees to take time to relax and recharge into action. Where rewards are transactional, recognition is motivational. Recognition is what drives behavior, builds connection, and breeds a self-sustaining culture.  Non-monetary recognition can take the form of saying thank you, publicly shouting out your appreciation of a job well done, providing new opportunities, mentoring/coaching, etc. People want to be seen and heard and recognized for the contributions they make. At HealthEdge we have an organic culture of appreciation best exhibited by our public and global “rockstars channel”. On this channel anyone can thank or give a shoutout to a person or team that made a difference, while the initial shoutout is amazing the best part is watching the shared celebration happen in supportive comments. Celebrate and recognize big and small efforts and be fair, consistent and equitable in rewards.

  1. Leadership

Finally, the last element critical to strong employee experiences is strong leadership. Leaders and managers are the lynchpin – from the behaviors they model, the vision they set, and the experiences they create with their teams. Leaders/managers bring the above elements to life and into everyday actions. Employees work for managers first, companies second. At HealthEdge we have focused on supporting, empowering, and equipping our manager and leader population to be brilliant at the basics: from how to host great 1:1s, to engaging in feedback, navigating potentially difficult situations, and strengthening their emotional intelligence (EQ). Assess how you are supporting the employee experience from this lens? Don’t lose site that manager relationships are the grassroots level of this work. 

The Dividends of Employee Experience

Employee experiences are an amalgamation of everything the employee interacts with beyond their day to day job tasks: people, process, tools, physical or virtual workspaces, etc. Most experiences are not under management’s control because true culture is what happens when no one is looking. The trick is focusing on what you can influence, facilitate, and improve. Remember to keep the end in mind as you embark on this work. Remember the interconnectedness of how employee experience, engagement, and satisfaction lead to improved business outcomes.  Happy, satisfied, engaged, empowered, connected employees expend discretionary effort. It is that effort of going the extra mile to; deliver better products and services, provide enhanced customer service, become brand ambassadors who speak highly about the company, that builds connection and loyalty resulting in people who are more likely to stay and refer others. You will know it is working when the virtuous cycle begins – when without intervention you notice these efforts in action organically.  There is so much you can start doing today to yield better employee experiences- let’s make work better!

Learn more about working at HealthEdge here.

Key Insights from Nationwide Survey: Understanding Your Medicaid and Dual-Eligible Members as Consumers

Tuning In: Recent HealthEdge Webinar Reveals Healthcare Consumer Study Results

During the recent webinar, Understanding Your Medicaid and Dual-Eligible Members as Consumers: What Matters Most Today, HealthEdge released the findings from its nationwide survey that gathered the opinions and perspectives of more than 2,800 healthcare consumers. Presenting exclusively to Association for Community Affiliated Plans (ACAP) members, the speakers focused their interactive discussion on the survey findings from the nearly 500 Medicaid and Dual-eligible plan members who responded.

The results shed light on member satisfaction, communication preferences, the role of social determinants of health (SDoH), and the trust today’s consumers have in health plans. Understanding these aspects is crucial for health plans to meet the evolving needs and expectations of their members. Here, we summarize the discussion.

Member Satisfaction: A Top Priority for Health Plans

Member satisfaction has become increasingly important, driving health plans to seek modern, digital transformation that facilitates a more connected, consumer-centric healthcare marketplace. Factors influencing the growing importance of member satisfaction include:

  • Consumer buying behaviors being shaped by retail experiences,
  • New market entrants setting standards for consumer-friendly experiences and driving the need for increased health plan agility,
  • Increasing availability of data sources and maturing interoperability standards,
  • Growing participation in Medicare Advantage, Medicaid, and individual marketplaces.

By keeping a pulse on what matters most to consumers, health plans cans can more effectively adapt, prepare for the next generation, and remain competitive in the evolving market.

Consumer Preferences and Expectations: Summary of Survey Results

The study revealed meaningful insights about Medicaid and Dual-eligible members:

  • Medicaid and Dual-eligible members tend to be more satisfied than their counterparts in Medicare and employer-funded health plans, but significant gaps remain.
  • Good customer service has emerged as a top priority for members.
  • Adhering to members’ communication preferences significantly impacts overall member satisfaction.
  • Consumers expect health plans to leverage SDoH data to deliver more personalized and relevant services.
  • While most consumers trust health plans to manage their insurance, they also hold health plans most responsible for high healthcare costs.

Now, let’s dive into the details.

The survey indicated that Medicaid and Dual-eligible populations show higher levels of satisfaction with 44% and 52% fully satisfied, respectively, compared to other groups. Conversely, the study revealed 44% of Medicare-only members were fully satisfied and 38% of members in employee-sponsored programs. Given this data, there is still ample room for improvement.

The study reveals the vital role care management plays in enhancing member satisfaction, providing a more personalized experience, and improving outcomes. The speakers explained that to scale care management efforts and achieve higher member satisfaction, health plans need modern technology in place. Technology can automate manual, mundane processes and empower care managers to be more productive, reach more members, and provide personalized engagement.

“We need to find ways to reach more members without taxing our nurses. When the right technology is present, payers are able to put the care manager in the center and empower them to be more productive to meet member needs at scale,” explained Jennie Giuliany, RN, Lead Clinician, Client Management, HealthEdge, GuidingCare.

Christine Davis, Senior Vice President, Marketing at HealthEdge also added, “Technology can help plans understand members holistically – medically, behaviorally, environmentally – and allocate the right resources based on populations. The right tools can help care managers scale so more members can receive the personalized engagement that previously could only be given by a care manager. For example, by improving care managers’ access to more real-time data, they have better insights immediately available. Technology can also automate manual tasks that take time away from care managers connecting with more members.”

Connecting with Members: Using Preferred Methods of Communication Improves Satisfaction and Outcomes

Medicaid and Dual-eligible members tend to prefer communication via phone, email and text or mobile app. Technology can equip health plans with the right tools to engage these hard-to-reach members. In addition, the study found that being able to communicate with members through multiple channels – and specifically their preferred channels – has a positive impact on overall satisfaction scores. Adopting an omni-channel communication approach allows health plans to connect with members through their preferred channels, which ultimately helps improve engagement and care plan adherence.

Holistic Inights and Actions: Using SDoH Data to Improve Member Satisfaction

A growing number of state policies now include SDoH. As SDoH data becomes more available, health plans can use this information to address health equity challenges. However, study participants demonstrated they are less than fully satisfied when it comes to their care manager’s ability to provide personalized care based on their personal traits, current economic conditions, and location or community. For example, results indicated:

  • 50% are less than fully satisfied with their care manager’s ability to provide individualized services based on their personal traits, such as race, ethnicity, gender, or religion.
  • 60% are less than fully satisfied with their care manager’s ability to provide access to essentials such as housing, food, utilities, or transportation.
  • 64% are less than fully satisfied with their care manager’s ability to provide services based on the location and/or community in which they live.
  • 69% are less than fully satisfied with their care manager’s ability to provide individualized services based on their current economic conditions such as education, employment, or income level.


To close these gaps in satisfaction, payers can turn to technology to easily identify at-risk populations and build more whole-person care strategies that can make meaningful differences in member outcomes and costs.

Using the right data and workflow tools, health plans can align individuals who have specific needs with more tailored services, such as access to housing, food, utilities, and transportation. Leveraging a care management platform that integrates with SDoH vendors can help accomplish this.

Understanding Member Needs and Gaps

When selecting a health plan, Medicaid and Dual-eligible members prioritize factors such having more services covered; offering benefits that align with service and medication needs; the ability to keep current providers; and in-network providers close to home or work.

However, the survey revealed that gaps exist in health plans’ abilities to address key member needs. Consumers identified the biggest gaps as:

  • Good customers service
  • Easy access to my health records
  • Incentives and rewards for health behaviors
  • Regular communication through preferred channels

Perceptions and Trust in the Health Plan Ecosystem

Medicaid and Dual-Eligible members generally trust health plans over other entities like the government to administer their health insurance. However, the research shows important trends emerging from different generations, such as younger members placing more trust in retail companies and being more likely to assign assigning blame for high healthcare costs to health plans. Understanding individual experiences and touchpoints within the healthcare ecosystem is essential for shaping perceptions and trust.

Actions for Health Plans to Improve Member Satisfaction

To enable care managers to be more efficient and effective, and to enhance current and future member satisfaction, payers can leverage modern care management solutions, like GuidingCare® and Wellframe from HealthEdge. The right solutions to support member experience should include key capabilities that allow health plans to:

  • Remain agile and adaptable to support regulatory changes
  • Automate multiple redundant and inefficient workflows
  • Expand into new markets and business models
  • Manage and support value-based care
  • Personalize member engagement at scale

Following consumer trends and needs allows health plans to improve member satisfaction and health outcomes at a time when the stakes have never been as high. To watch the full webinar, visit the HealthEdge website here.