What Health Plans Can Learn from Consumer Brands

Health plans are sacrificing quality performance because they're treating members like patients instead of consumers.

The same person who gets a one-tap text from their mechanic, schedules a dinner reservation on their phone in 60 seconds, and tracks their Amazon delivery by the hour is also being asked by their health plan to log in to a portal, search for an in-network provider, compare options, and then call, navigate phone trees and wait on hold to schedule a provider visit.

Too many members don't make it through all the steps. Not because they don't care about their health — because the experience highlights friction with little immediate benefit.

That drop-off shows up in gap closure rates. It shows up in HEDIS scores. It shows up in Stars Ratings.

Consumer-driven brands know the fewer the steps, the fewer the opportunities to drop off. They have frictionless experiences down to a T, enabling people to complete a task before they have an opportunity to second guess. So, what’s taking healthcare so long to catch up? When there’s so much on the line for payers, providers and members, healthcare organizations still have yet to adopt this same consumer-driven approach.  

Consumers have been trained for something different

Every industry that touches consumers daily has been moving in the same direction for fifteen years: remove the friction from the customer’s side and put it on the business’s side. Rideshare apps replaced calling a cab. Reservation platforms replaced calling ahead to check for a table. Scheduling software replaced phone tag. Layer in texts and push notifications and businesses have a customer retention engine that never quits.

This is the baseline that most health plan members have when interacting with any company. When something requires more steps than it should, people don’t complain — they give up.

Annual wellness visits, preventive screenings, follow-up appointments. These are exactly the kind of tasks people mean to do but don’t — not because they don’t care about their health, but because the path to completion is long.

Changes in member behavior are influenced by consumer brands

The standard outreach model most health plans use is awareness focused. It expects members to independently take action through a multi-step process to complete the task they were reminded of. Historically, health plan outreach has used rewards and health education to drive motivation to complete those tasks.

“We know that as member expectations of their health plan grows, education and rewards only go so far,” says Kimberly Swanson, Chief Strategy Officer at Healthmine. “There’s a significant discrepancy between what members experience in their day-to-day life and from their health plan. That’s a barrier to plan performance, without question.”

Members know what frictionless experiences look like now. They’re seeing it firsthand in nearly all areas of their lives, except with their healthcare, which in turn puts the spotlight on the abrasion they do experience in their healthcare journey.            

The distinction in success metrics

When health plans rely on mailers or automated phone call reminders, success is measured by the task being completed. The postcard was delivered and the member received the phone call. But these are vanity metrics because the gap still exists by all other performance measurement.

A member who reads a mailer and a member who has a confirmed appointment on their calendar are not at the same point in the care journey. Most outreach programs reach the first milestone and consider deliverability a win.

“While important to track channel deliverability because it represents how reachable your population is, it’s more important for it to be the foundational metric that plans layer outcomes-focused results on top of,” says Swanson.

QRM Connect™ is built around the action milestone. Unlike outreach that stops at the reminder, it doesn’t just notify — it books. Starting from the first message, the member is engaging in a conversational workflow that pulls them towards scheduling by:

• Confirming the patient’s identity
• Confirming an established provider or finding a new provider
• Capturing appointment date and time preferences
• Scheduling the appointment on behalf of the member using a conversational, multi-lingual AI agent
• Confirming the appointment with the member
• Providing methods for rescheduling

For the member, it’s a few taps in the same text conversation, or questions answered over the phone. For the plan, it’s more scheduled provider visits and gaps closed. This is how member outreach moves beyond awareness to complete the action stage.

What QRM Connect’s scheduling looks like in practice

A member receives a text message or phone call. The message identifies their plan and the care they’re due for. After two identity verification questions, the agent surfaces in-network provider options nearby, and confirms a time. The appointment is on the calendar.

One conversation. No separate call to the provider’s office or portal navigation. No drop-off point where the member has to figure out what to do next and the plan has no visibility.

The visit that would have stayed on a to-do list gets scheduled. The gap that might have stayed open through the measurement period gets closed.

“This is a solution that health plans can implement in just a couple months and doesn’t require any electronic health record (EHR) integrations,” says Swanson. “What’s so special about QRM Connect is how our team used our experiences in both leading health plan operations often being frustrated by member inaction, and as consumers who know how we want our own healthcare services to operate.”

Take a self-guided tour of the text-based experience, delivered via RCS and SMS.

The payer’s role in scheduling support

The difference between telling a member what to do and helping them do it shows up in gap closure rates, scheduling completion and HEDIS performance at the end of the year.

Health plans are accountable for whether care actually happened. That’s a different job, and it requires outreach built around completing the visit — not just initiating the journey.

Don’t let inaction leave your plan performance behind. Find out how we can help.