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Get to Know the Payer Industry Trends

Learning Objectives

After completing this unit, you’ll be able to:
  • Describe what members want from their payers.
  • List the challenges payers face.
  • Explain how you can use Health Cloud to address payer challenges.

What Do Healthcare Consumers Want?

In this age of digital transformation, healthcare customers and patients want connected, collaborative healthcare experiences. What we have now is the emergence of the empowered healthcare customer. Members are more informed about their care options. And they prefer an integrated care experience that uses technology to combine organizations, providers, call center agents, and sites.

In this module, you'll learn how healthcare trends are shaping new experiences and why payers need a technology platform that offers a unified omni-channel, covering interactions from sales to sites.

Customer experience is the key driver of market trends. Payers have to understand member expectations to stay on top of the game. With digitization and the emergence of the informed customer, members want a personalized, connected service. To provide such a service, payers need an omni-channel platform that utilizes data to offer a personalized customer service. But before we get there, let’s explore the trends in customer expectations that shape the healthcare market.  

A child hugging a pregnant woman in the center of frame. They are surrounded by the six trends shaping healthcare industry.

Virtual care: Members want to connect one-on-one with call center agents. More than 60 percent of members want call center agents to follow up on their health outcomes.

Complete health records: Members want easy access to their data. Almost 60 percent of members think it’s important for call center agents to know the details of their medical history after they identify themselves.

Access on any device and 24/7 service: Members want seamless, around-the-clock customer service across devices, without being transferred or put on hold, or having to repeat themselves.

Affordable care and personalized treatment: Overall, members expect personalized care plans and treatment that won’t bankrupt them.

But how important are these customer demands? According to the 2019 Salesforce State of the Connected Customer report, 84 percent of customers value the experience a company provides as much as the products—over 60 percent of customers said they’re willing to pay more for better service. That means, a majority of members are willing to change healthcare plans for a better experience.

Common Healthcare Hurdles

The healthcare industry is complicated. Payers face a long list of challenges, including rising member expectations, changing population health dynamics, fierce competition, lack of interoperability, and strict government regulation. Let’s look at some of the common hurdles.

An image of a person in a hurdle race with each hurdle representing the five issues that payers face.

Manage sick and aging populations: About 10,000 people age into Medicare every day, and one in two US adults have chronic health conditions. Payers face increased pressure to effectively serve this population at scale.

Deliver care everywhere: Amid retail’s influence on customer expectations, the healthcare industry must step up to offer similar experiences. Members want a seamless, digital journey that is accessible from their devices. Payers have to ramp up to provide remote care, enable virtual visits, and deliver the right care through the right channels at the right time.

Personalize member engagement: The market demands relentless focus on the member as an individual. Over 80 percent of members want guidance in their health journeys, and only one in four members trust payers. Payers are under pressure to transform the member experience by putting the members at the center of their services.

Fierce competition: Mergers and acquisitions, newer business models, and increased competition dominate the payer market. New entrants partner with local pharmacies to expand their footprint. Insurance companies roll out more locations with specialized wellness programs to engage members. Payers such as CVS/Aetna, Cigna/Express Scripts, and Humana with Kindred at Home focus on Medicare programs. New entrants such as Bright Health, Clover, and Devoted Health Plans zero in on Medicare Advantage. Together, they turn up the heat on competition.  

Focus on driving sales while reducing cost: There is intense focus to build individual business, especially in Medicare and Medicaid. While small businesses focus on growing sales through tools for broker quoting, large businesses promote smarter member engagement and wellness programs.

Enter Health Cloud

When the British mathematician Clive Humby said, “Data is the new oil,” he meant more than just using data for business profits. He also said, “It’s valuable, but if unrefined it cannot really be used,” which describes the current payer market. Payers can access huge volumes of member data that’s extracted from medical records and case histories. But without a central platform to view the data, payers have too many places to look. Inefficiencies arise from disparate, manual systems and data sources.

Payers must know and serve the whole person. In this data-driven world, call center agents need smarter data visualization to answer member calls easily and accurately. Payers and case managers also need a centralized view of the member to decide on the best course of action. With Salesforce Health Cloud offerings such as Provider Search, Care Plans, Social Determinants of Health, and Utilization Management, payers can do just that.

Health Cloud also offers the Member Success Platform. It provides a 360-degree view of the member on a unified omni-channel, covering interactions from sales to sites. The platform supports nine functions to effectively serve members.

An image of a man smiling in the center. He is surrounded by the nine Salesforce functions that support the payer industry.

Member and provider collaboration: Enable member engagement with a group of providers, case managers, family members, and organizations to support the member journey.

Personalized member engagement: Engage members in their health journey from awareness and enrollment to health management and wellness, with customized content on their preferred channel.

Connected member care management: Collaborate with care teams using longitudinal timelines, clinical data, and Social Determinants of Health to create Care Plans, identify care barriers, and plan actionable solutions.

Provider relationship management: Expand your footprint with provider network management for recruiting and onboarding, and collaborate with providers on contracts and care management.

Effortless member service: Ensure seamless member support experience through a single view of omni-channel interactions and self-service options.

Real-time actionable insights: Use Einstein-powered dashboards to gather real-time insights about population health and performance goals.

Integrated core systems: Efficiently integrate data across core systems and functional solutions, using APIs to create a unified engagement platform; enable interoperability and deepen relationships across the enterprise.

Accelerated application development: Optimize member, broker, provider, and employer experience with high-performance, high-volume applications.

Individual, group, and broker sales: Simplify lead management, quoting, and enrollment; automate quoting for brokers through innovative tools; and optimize new group sales, renewals, and quote-to-care processes.

The payer landscape has transformed from disparate case files and sticky notes to customized healthcare reminders on smart watches. In keeping with the changes, payers are adopting digital strategies to engage members in their health journeys. From provider to call center agents, Health Cloud offers a complete healthcare solution to help you connect every person involved in the member’s health journey. Good service helps foster member loyalty.


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