Top Member Education Strategies for High Performance Network Benefits

August 04, 2023 - As payers and employers gravitate toward high performance networks, there is a demand for better member education around these plans’ benefits.

Regulators have expressed concerns that high performance networks will limit members’ access to care. Since 2013, the National Association of Insurance Commissioners (NAIC) and federal agencies have implemented various regulations to ensure network adequacy and avoid surprise billing.

However, payers see these networks as an opportunity to lower healthcare spending. With national spending expected to grow on average 5.4 percent each year from 2022 to 2031, the urgency to control healthcare costs is high.

High performance networks may be part of the solution. These plans are 16 percent cheaper than broad networks and enrollees in these selective networks spend $761 less each year than their counterparts in open networks. However, researchers noted that these results may reflect price changes more than utilization reduction.

As a result, more than seven in ten marketplace plans have adopted narrow networks. Additionally, 21 percent of employers sponsored narrow networks in order to address affordability challenges.

These plans can only be effective at reducing costs if their members understand their benefits and the advantages that narrow networks offer. Member education is particularly important when a member’s provider is not included in the narrow network.

Payers may need to partner with providers, go beyond the explanation of benefits, and leverage omnichannel tools to communicate with members. Their educational efforts may also vary based on the type of high performance network.

Partner with providers on communication, referrals

If preferred providers are willing to communicate with members about their benefits or provider network changes, payers should leverage the opportunity for member engagement. However, not all providers will be open to that level of differentiation with a payer.

Providers are most likely to partner with payers to improve the referral process.

Physicians create trusted referral connections. When payer networks change or become narrower, preferred providers might find their usual referral patterns interrupted. When a provider is no longer in-network, payers have to perform a messaging campaign to their other preferred providers so they know the best substitute referral.

Communication—or lack thereof—with providers about new referral options affects not only provider workflows but also member experience. When their primary care doctor sends them to a specialist who is not in-network, it can delay or disrupt members’ treatment.

Moreover, members trust their providers’ referral recommendations. Getting ahead of potential referral disruptions can help maintain that trust and member satisfaction.

Do not rely on the explanation of benefits

By law, many payers must distribute an explanation of benefits (EOB) to members. EOBs summarize the cost of a medical service or product, detailing what the insurer paid and how much is left for the member to cover. The document serves its purpose for regulatory compliance but does not offer much value beyond this function.

Payers cannot rely on the EOB to inform members about their coverage. Instead, they should be proactively informing members of any changes, such as copay adjustments or network shifts.

Timing is an important part of this effort, particularly for Medicare Advantage plans and health plans on the Affordable Care Act marketplace. Payers should reach out to members with benefit information during the annual enrollment period and before the January 1 deadline for enrollment.

Leverage omnichannel communication tools

The tools that high performance network plans use to engage members do not differ drastically from other networks’ apparatuses.

The most critical resource in the member education toolbox for high performance network plans is omnichannel communication. Payers’ communication channels should span the full range of their members’ preferences.

Experts recommend learning communication preferences at the very first touchpoint for new members: onboarding. Members may prefer emails, texts, phone calls, online portals, apps, online chats, or other methods of communication. Payers should collect data on member preferences during the onboarding process and document the results.

This step is crucial for developing the payers’ identity as a trusted resource. If payers can establish this role early, members will be more likely to trust their provider network choices.

Tiered networks: incentivize members to use a subset of in-network providers

Strategies will vary based on the type of high performance network a payer is offering.

Tiered network plans give members access to a broad range of in-network providers. However, they break the network into tiers, with the top tier—or preferred—providers being the most affordable and the highest quality. Copays and cost-sharing for tier one providers will be lower than the other tiers to encourage members to visit high-quality providers.

When offering a tiered network, payers will want to educate members on the economic benefits that they could experience in the plan.

Tiered networks can result in cost-savings outside of copay reductions. One major payer’s tier one network resulted in a 10 percent lower cost of care when compared to its non-preferred network providers by reducing complications and other low-value spending.

In addition to the economic benefits, payers offering tiered networks should emphasize the members’ flexibility to select specialists from the broader preferred provider organization network if needed.

This strategy only works if payers have appropriately differentiated between their preferred and non-preferred providers. If there is too much overlap between in- and out-of-network providers, the incentives will fall flat.

Narrow networks: emphasize the benefits of a limited network

In a narrow network, payers design a network that strictly consists of high performing providers. These providers must offer high quality care at low cost. They may also need to perform clinical documentation tasks and comply with quality programs in Medicare Advantage or Affordable Care Act marketplace plans.

Member education in narrow networks may be simpler than it is in tiered networks. Most members will check in advance to ensure that their preferred providers are in-network.

Some health plans emphasize the role that care coordination plays in narrow networks. Payers might position the primary care provider at the center of a patient’s care team to ensure organized, timely care delivery.

For this to work, plans must choose their providers wisely to ensure that members’ needs are covered. Narrow networks that satisfy members’ needs can be agile, but narrow networks that do not have the capability to handle members’ needs become too restrictive.

Narrowing a network versus offering a new narrow network

Few payers choose to narrow an existing network. It is much more common to offer a new narrow network instead of tampering with an existing one because losing providers is a significant factor in attrition.

If a payer chooses to narrow a network and eliminate certain providers, the organization must estimate how many plan members visit those providers. It should predict the percentage of members that might leave due to the loss of their primary care provider.

Then, the plan should reach out and connect those members to a new in-network provider. The message to these members should be highly personalized. Any plan employee reaching out to the member to discuss the changes should provide an alternative provider that the payer thinks will satisfy its members’ needs.

As employers and payers explore high performance networks’ potential to reduce costs, member education will be critical to successful implementation.