While member experience and member engagement departments are often referenced interchangeably, there are some distinct differences.

Member experience departments focus on ensuring a positive experience for members so that members choose their plan, renew their plan, and take recommendations from their plan. Member engagement departments delve deeper into that last item, “taking recommendations from their plan”, to try to influence member behavior. This can range from enrolling in applicable care management programs, to selecting an in-network primary care physician, to closing care gaps to increase plan quality ratings, to receiving benefits from community-based organizations to inflect social determinants of health. All these behaviors impact member experience, as well as care quality and medical spend.

Since member experience and member engagement goals are often interconnected, these departments must work together and assume responsibility for all interactions between the plan and members. (In fact, some plans have a single department for member experience and engagement.) These departments must also work with provider-facing departments because member experience includes patient experiences and interactions with providers.

What member experience and member engagement departments do

• Concierge/member advocate services
• Call center management
• Member onboarding
• Data review
• Member guidance
• Plan portal updates
• Behavioral economics
• Member outreach
• Quality improvement support
• Vendor management
• Community outreach programs
• Member feedback surveys
• Digital tools administration

The two most common ways member experience and member engagement are organized at a health plan are centralized and dispersed. In a centralized model, there is one main department in charge of member experience and/or member engagement, often led by a "chief experience officer." This centralized department works with other departments across the organization to ensure that all experience and engagement efforts are aligned.

In a dispersed model, responsibility for member experience and engagement is spread across the organization. Specific member experience and engagement leaders are embedded into various health plan departments — often under the ethos that the member should be at the center of everything the plan does. For example, even provider-facing plan departments have a role to play in member experience because the experience members have in a doctor’s office as a patient is part of the member experience. There could still be a chief experience officer in this model, but they would only have a small team and spend more of their time working with other teams.

There is no single, correct model. Most plans use a mix of these 2 approaches. To make matters more complicated, sometimes there is no specific member engagement department or leader, and member engagement is inherently assumed by the member experience and medical spend management departments.

In this case, multiple teams — such as the call center, marketing, sales, and product design teams — support member experience. These teams generally report up to the chief experience officer or the chief operations officer. The teams are measured against key performance indicators (KPIs) related to net promoter score (NPS), click-through rates, and revenues from new members or renewals.

Product design plays a large role here because additional services in products can entice members to choose that product and have higher satisfaction, but many products also incorporate cost sharing to encourage member engagement and thoughtful care decision-making. However, because health care doesn’t have robust price transparency mechanisms, cost-sharing is a blunt instrument to drive member engagement, and one that can’t be used in all lines of business (such as Medicaid managed care).

There are other teams, such as care management and population health teams, responsible for managing medical spend. These teams usually report to the chief medical officer and are more clinical in nature, focused on KPIs such as total cost of care and reduced ED utilization.

Member experience and medical spend teams are separated to enhance organizational structure as it could be unwieldy to have one department manage all these functions. However, with separation comes silos between the member experience and medical spend teams, which means health plans can miss the opportunity to engage members in their own care.

Member experience and member engagement departments work with many vendors for a wide range of tasks. In fact, plan experience/engagement leaders say they are approached by new vendors daily.

Below are three ways plans organize experience/engagement vendors. Examples are provided for clarity, but Advisory Board remains vendor agnostic and is not recommending any of the vendors listed.

1. Vendors by whether they are internal or external facing

One way to organize member experience/engagement vendors are whether they are internal or external facing. For example, plans often look toward vendors to help them organize and analyze their member data to inform their member engagement initiatives. This vendor is internal-facing, since it doesn't interact with plan members directly. However, the vendor still plays an important role in helping plans with member experience/engagement.

A popular internal vendor example is Salesforce. Salesforce is a customer relationship management (CRM) vendor that helps health plans collect, keep, and organize member data so the plan can coordinate outreach campaigns and maintain relationships with members.

2. Vendors at different points in the member journey

Health plans can also organize vendors by the point in the member journey the vendor supports. For example, certain vendors help plans craft personalized messages for members, some vendors help plans find the correct phone number or email address of members, and other vendors help plans deliver messages to members through mass email or phone campaigns. Because these vendors specialize in different offerings at various points in the member’s journey, plans partner with multiple vendors to push on initiatives in a chronological fashion.

One vendor that focuses their work on the different steps in members’ health journeys is mPulse. mPulse uses conversation AI and data triggers to identify members who pose a risk to the health plan’s goals (for example, perhaps because they aren’t attending their annual wellness visits) and reaches out to those members member with resources and calls for action.

3. Vendors organized by disease state

Member engagement departments work closely with care management and disease management departments because members who qualify for these programs are often the most important members to engage from a quality and cost perspective. There are vendors who provide disease-specific care management to halt or delay deterioration of a member's health. For example, a health plan might work with one vendor for a diabetes care management program and another for weight management. These vendors may offer digital support to make their programs more scalable.

One example of a vendor that is specific to a disease state is Headspace Health. Headspace Health providers teletherapy services as well as a mindfulness app for members with all levels of behavioral health conditions.

Below is a collection of stories of how health plans are trying to improve their member experience and member engagement processes. To demonstrate the range of responsibilities and activities that fall under member experience and member engagement, we have intentionally curated a disparate set of examples.

Member experience

• Blue KC makes every plan employee responsible for member experience by tying engagement to the employee’s annual bonus through an internally created metric: the customer effort score. Blue KC uses this metric along with data from the call center, surveys, and emails to identify specific member concerns and requests to ease member experience.
• Moda Health modified their login page to warn members if they were about to be locked out of their account for too many access attempts. This showed a significant reduction in call center traffic for login issues.
• Humana created a triage model for its call centers, using artificial intelligence to predict the likely needs of callers and direct them to the appropriate associate. After implementing this model, issue resolution increased and NPS improved.

Member engagement

• Amerihealth DC partnered with an existing community organization that utilized EMTs to conduct house calls to screen for diabetes. This resulted in improvement in at least one biometric measure (HbA1c, resting blood pressure, and/or weight).
• Oscar uses member profiles to recommend the next best action for members’ care management and set campaign targets through a program they built, Campaign Builder. The program creates scalable, personalized interventions with automated workflows to improve member experience and satisfaction.
• Independent Health identified potential detractors through claims and case management data to resolve issues through outreach and navigation assistance. This led to a 5-star rating and 90% of members having their needs met and their issues resolved without complaint.