Optimizing health care through provider engagement

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EY - Yele Aluko

Yele Aluko,
MD, Chief Medical Officer,
Ernst & Young LLP

EY - Sandeep Munnangi

Sandeep Munnangi,
Senior Consultant,
Ernst & Young LLP

EY - Tim Calhoun

Tim Calhoun,
Government Sponsored Health Leader,
Ernst & Young LLP

Consumer experience has driven business transformations spanning all industries today. Though there is no standard industry definition of member or consumer experience, in the health care industry, it is best defined as the degree of member or consumer satisfaction with services rendered by the provider and received by the member or consumer, relative to the cost of purchase of services.

Many of the traditional methods used to evaluate member experience in health care, such as surveys, questionnaires and focus group discussions, do a relatively good job in providing insight on member experience. However, metrics for tracking member experience are often inconsistently aligned to provider performance.

Furthermore, member experience is often based on outcomes that may be outside the control of the provider. Providers do have a significant degree of influence on member satisfaction, driven largely by the perception of a favorable outcome of the member’s condition.

As such, linking provider compensation to member experience will focus efforts on the delivery of the best clinical quality outcomes while encouraging physicians to influence non-clinical processes that impact consumer satisfaction, such as cost of care delivery and other experiential factors. This strategy must be considered as an integral component of the framework for optimization of the member experience.

Providers are most often the first point of interaction for members in the health care ecosystem and are integral in shaping the overall experience. In addition, providers are likely to have the highest number of touch points and interactions with members along their journeys as they navigate the complexity of the value chain. Since enhanced member experience is pivotal to the delivery of health care value, payers will do well to work collaboratively with providers to shape the member journey.

Given the limited resources driven by increasing regulatory and financial constraints imposed on both payers and providers, the following pointers need to be considered by payers for collaboration with providers in improving member experience:

  • Share information with providers

    Payers use a multitude of systems to gather information about member experience. Some of the commonly used data sources are call center surveys, mock Consumer Assessment of Healthcare Providers & Systems (CAHPS) surveys, complaint forms, focus groups, and information and feedback gathered through online portals. Payers should identify information specifically related to provider touch points and interactions, and transparently share feedback received from members with providers on a regular basis.

  • Develop a physician attribution model

    Members often visit a multitude of providers anchored around the primary care physician (PCP) and often, member experience is a summary of their interaction with all such providers. Payers should work with providers to develop a member-physician attribution model to trace back member experiences to the respective provider acutely.

  • Establish more transparent and functional relationships with providers

    Payers should use claims data to identify providers servicing significant numbers of their membership. Payers should identify providers for whom your membership makes up a significant volume of the total membership they serve. Payers should focus on top member service providers and leverage the resources in your provider relationship team to have an ongoing dialogue about member experience.

  • Empower providers with data

    Payers should be transparent with the providers and share the information received from members. Payers should build easy-to-access dashboards for providers detailing the metrics being used and data sources. Payers and providers should evaluate and revise the pay for performance metrics on an ongoing basis.

  • Develop incentives

    Establish a pay-for-performance model directly linked to both member experience and key clinical and operational metrics, supported by data collected as a part of member experience tracking. Members should be encouraged to attribute ratings of health care quality transparently, with visibility to their providers. Most of the payers in the market are already working toward value-based payments involving providers and developing pay-for-performance models based on health outcomes.

    However, several of these are more focused on cost containment strategies and less on a holistic assessment of patient experience and value. Given the role improving health outcomes, optimizing cost of care delivery and patient satisfaction has on overall member or consumer experience, payers should leverage existing pay-for-performance mechanisms, supported by robust data-analytical methods that capture and share information on provider and health system performance with providers and consumers.

    In the traditional fee-for-service (FFS) environment, novel alternative payment models (APMs) are met with provider skepticism, and demonstrating a clear industry return on investment (RoI) to this strategy has proved elusive. However, several payers across the industry are already working with providers to shape member experience.

    Case in point is the Medicare Advantage Program, a Medicare Plan provided by private insurers where payers servicing Medicare Advantage are exploring innovative member interaction models to track plan and provider performance and improve health outcomes. Using star ratings by which members rate plans and providers within this program, overall member experience measures account for more than half of the overall star-rating measures.

    Medicare financially rewards those Medicare Advantage Plans with high star ratings and penalizes those with low ratings. Similarly, it rewards high-performing Medicare Advantage Plan providers with quality bonuses. As such, both the payer and the provider share risk for performance, sharing incremental revenue gained from higher star ratings.


In summary, there is a growing emphasis on enhanced member experience for improved delivery of health care value. Payers need to derive a process that is focused on tracking and improving the overall member experience, empowering providers with individualized data about patient satisfaction and experience, and aligned around shared financial risk.

Providers need to be willing to be measured objectively and transparently, and should be receptive to well-constructed pay-for-performance models directly linked to key operational metrics and member experience.