Enhancing the member experience: A payor’s guide for 2025

As we kick off 2025, healthcare payors have an array of opportunities to improve the member experience, while meeting new regulatory requirements. With a focus on patient-centered care and evolving regulations, here are four key strategies for payors to consider.

Harnessing the power of AI

Artificial Intelligence is transforming healthcare by streamlining the identification of member issues and discrepancies in care for both payors and healthcare providers. By utilizing predictive analytics, payors can proactively identify challenges, implement timely interventions, and tailor strategies to enhance health outcomes for vulnerable populations.

Qualtrics AI® solutions enable payors to effortlessly shift from insights to actionable solutions – transforming complex data into clearly delivered, immediate insights and automatically triggering necessary workflows.

Optimizing contact center performance

In the competitive landscape of healthcare, high-performing contact centers play a pivotal role in ensuring quality performance for health plans. Their influence on customer satisfaction and Quality Ratings cannot be overstated. By effectively understanding call drivers, identifying member pain points, and assessing agent knowledge and efficiency, health plans can leverage insightful data to foster continuous improvement, ultimately enhancing the member experience and delivering superior quality outcomes.

The Qualtrics Quality Management solution enhances this process by providing real-time feedback to agents and integrating various customer interaction data into a comprehensive Voice of the Customer (VOC) perspective, ultimately elevating service delivery and member satisfaction. Agents are equipped with a dashboard that measures their performance based on skill application, communication metrics, and engagement levels, fostering an environment of continuous growth and improvement.

Strengthening provider-payer partnerships

The partnership between providers and payors is integral to the patient experience. Enhanced communication and collaboration can significantly improve care delivery, ensuring patients receive timely support. Moreover, positive patient experiences are correlated with better clinical outcomes, making it essential for payors to foster strong relationships. Health plans that implement integrated programs combining member and patient feedback with provider listening initiatives are better equipped to advance these critical partnerships.

Navigating regulatory changes in Medicare Advantage

Looking ahead, several proposed regulatory changes will impact Medicare Advantage plans. Notably, certain measures in the Star Ratings program may be retired, emphasizing the importance of CAHPS performance as a key metric for assessing plan quality. Additionally, new rules will introduce a Special Enrollment Period for dually eligible individuals, highlighting the importance of aligning member needs with suitable plans to improve retention rates.

With the introduction of the new Health Equity Index (HEI), which is being measured in 2025 and will replace the Reward Factor in the 2027 Star Ratings, it’s essential for Medicare Advantage plans to leverage data collection and analysis tools. Qualtrics helps identify how social risk factors (SRFs) are impacting member experiences. By utilizing this data to optimize outreach strategies, plans can not only improve their performance metrics but also gain an omnichannel view of critical SRF information.

By embracing these focus areas, payors can navigate regulatory changes more effectively and enhance both member and patient experiences. Prioritizing member needs will be essential for improving Quality Ratings and ensuring success in the competitive payor landscape throughout 2025 and beyond.