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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