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Today’s consumers expect their health plans to be active partners in their healthcare journey, offering affordable options, easy access to care, and robust support for managing chronic conditions. This shift places health plans at the core of the healthcare experience, requiring them to adapt to the evolving member expectations. The rollout of the Centers for Medicare & Medicaid Services (CMS) Health Equity Index (HEI) further underscores this shift by integrating several Star measures and Social Determinants of Health (SDOH) into its evaluation criteria. Studies show that clinical care only accounts for about 20% of health outcomes at the county level, while social factors like housing, food security, education, and employment can influence up to 50% of outcomes. By 2027, the full integration of HEI will impact Star Ratings, pushing health plans to address health disparities more aggressively.
In addition to the focus on SDOH, there is a growing recognition of the importance of Digital Determinants of Health (DDOH). DDOH includes digital factors—such as ease of use, digital literacy, and internet access—that affect people’s interactions with healthcare services. They illustrate that a person’s ability to use digital tools can significantly impact their health outcomes. For example, in areas with limited internet access, adopting low-bandwidth digital solutions tailored to common mobile devices could enhance member engagement and improve health outcomes. This new focus on DDOH highlights the need for health plans to integrate digital inclusivity into their strategies.
These shifts present a valuable opportunity for health plans to harness AI and data analytics to gain deeper insights, understand the impact of SDOH and DDOH, and incorporate this knowledge into their care strategies. For members, insight-driven interventions—such as encouraging wellness visits and essential screenings—enhance risk assessment, prevention, and care, leading to better health outcomes and greater satisfaction. For health plans, leveraging these strategies supports the development of well-structured programs that improve member acquisition, retention, and overall financial performance.
Blending Intention with Action
To align with changing member expectations and uncover new opportunities, many health plans are already employing AI and analytics. For instance, Highmark Health uses AI to combine SDOH data from its network, public sources, and proprietary information to create comprehensive SDOH assessments. These assessments are integrated with area-level data through machine learning to estimate SDOH risks for members who are not actively engaged, effectively identifying needs and closing care gaps. Similarly, Kaiser Permanente has expanded its screening processes to cover the entire member population, not just vulnerable Medicare and Medicaid groups, using an AI-based tool to better identify and address member needs.
Investing in AI and analytics gives health plans insights beyond traditional claims and medical data. By analyzing SDOH and HEDIS data, health plans can identify individuals at risk for chronic conditions like diabetes and address challenges such as readmissions and social barriers. This enables more proactive engagement and optimized support for all members, enhancing care quality and closing gaps. Cigna, for example, has utilized HEI metrics with SDOH data to enhance outreach to high-risk populations, achieving a 40% improvement in care access for minority groups.
Building Trust-Based Communities
In a time when healthcare consumers want to feel heard and valued, omnichannel engagement does more than boost member satisfaction—it builds trust-based communities. These communities thrive when members’ questions and concerns are addressed with empathy and proactive support, fostering stronger engagement and better outcomes. Digital-first engagement is key to building these communities; recent reports indicate that one in six adults, including a quarter of young adults, now use AI chatbots for health information and advice, opening new avenues for deeper relationships with members.
Omnichannel engagement also plays a critical role in managing acquisition costs, improving retention, and meeting CMS’s updated Medicare Advantage (MA) quality scores, which emphasize member experiences. Health plans can connect with members via chat, SMS, or email and provide empathetic voice support to ensure comprehensive care.
For example, a health plan client experienced a 300% increase in scheduled appointments and over 100,000 member-initiated calls after launching an omnichannel outreach strategy for members with chronic conditions. Combining AI-driven workflows with empathy training for support agents can further enhance the member experience. AI provides real-time guidance, offering suggestions and insights to resolve issues quickly, while empathy training ensures that support resonates with members across their preferred channels.
Shaping Tomorrow’s Ecosystems of Care
Addressing SDOH barriers and supporting members’ health throughout their lives requires innovative thinking from health plans. This means adopting a holistic approach that combines digital tools, AI, and analytics with a focus on human-centered design and user experience. To achieve this, health plans must effectively aggregate SDOH data, understand the impact of DDOH on their digital engagement strategies, and embrace a systems-thinking approach. By creating products and services that cater to diverse member needs—including those from historically marginalized communities—health plans can build a more connected, responsive, and equitable healthcare ecosystem, ultimately driving better health outcomes for everyone.
By integrating these elements and adopting a more holistic approach, health plans can become proactive partners in their members’ health journeys, providing the right support at the right time and place. This comprehensive, inclusive approach not only aligns with regulatory requirements like the HEI but also enhances overall member satisfaction and trust, further cementing health plans’ central role in the healthcare experience.
This article was written by Jordan Armstrong, Chief Revenue Officer, ResultsCX for Healthcare IT Today.