The Centers for Medicare & Medicaid Services (CMS) decision to double the weight of the patient experience measure in CAHPS ratings by 4x (vs. 2x in previous years) will go into effect in 2023. Plans have been innovating and operationalizing processes to optimize every aspect of member experience from onboarding and customer service to coordinating care and resources.  When members are engaged, ratings and reimbursement improve.  

In addition to finding new ways to engage members, health plans need to be able to scale solutions to member populations.  A virtual specialty care model is ideal for both scaling and personalizing to the needs of every member.  


1. Trusted, knowledgeable clinician as the first point of contact

As a provider of virtual care since 2009, we have learned that the first point of contact with the member is critical in earning their trust and the overall success of the program. Many of today’s chronic care programs are digital first and/or use a (non-clinical) call center model, which works great to reach volumes of members quickly.  However, with a Medicare population in particular, what engages members are clinicians trained to establish where the member is in managing their personal chronic care health journey, and then assess the level of motivation before determining appropriate objectives and plan of support.   

Engaging with someone who understands their disease state(s) and day-to-day struggles allows members to be more honest and build rapport in a way that is genuine and begins from the very first interaction.  With this approach we have consistently achieved 45%+ member enrollment rates for our programs.   


2. Clinicians have the specific skillset and insights to address whole member needs; and the credentials to take action in the moment

It is not just about the chronic conditions being managed, but about assessing all of the members’ needs and providing immediate feedback and support.  Every interaction can present with unknown complexity and being ready with a combination of skills is critical: 

  • Motivational interviewing, active listening helps members feel heard and respected 
  • Assessing and determining best mode of communication and the appropriate number of interactions needed to support the individual 
  • Assessing and determining technology preference, ability, and barriers (i.e., SDOH) 
  • Ability and insights to focus on specific needs based on information shared, optimizing the value of each interaction 
  • Helping members break down information and connect the dots between their participation and how it directly impacts health outcomes and other aspects of their personal life 

The same credentialed clinician can act, resolve issues, or connect members to resources in the same conversation.  This is important when uncovering social determinants of health and other barriers.  Collecting information without the ability to connect members to resources adds to the challenge and leaves members frustrated.  Ready at hand, appropriate resources help address fundamental barriers in conjunction with care management.   

With an extensive understanding of the disease state and treatment options – such as medications, side effects, labs, complications, goal numbers, devices used for management, etc. – these clinicians can also help uncover and find solutions to member issues, addressing them on the spot.  A member example:  

An individual expresses frustration with no change in blood glucose numbers despite continued increase in insulin by a physician.  After reviewing numbers with the individual, the clinician proactively walks through the injection technique only to discover the individual was not removing the inner needle cap on the insulin pen. It could also be noticing dexterity issues with an older adult who is still using vial/syringe and assisting them in changing to a pen where they can dial the dose.   


3. Virtual specialty care provides quality and scalability with digital health and interoperability as its backbone

Virtual specialty care is not just a virtual, more clinical version of care management, but an integrated model that leverages digital health, data, and interoperability at every touchpoint – before, during, and after care.  It’s impossible to scale personalized care for every member without the support of a technology platform that supports omni-channel communication, information sharing, actionable insights, and outcomes measurement.   

While health plans are data rich with member information, they are data poor on readily accessible medical history.  Imagine having connections to multiple sources, including standardized, trusted, secure sources, that include data such as demographics, pharmacy fills/refills, medication history, diagnoses, etc. and are leveraged at each touchpoint to create better user experiences.  Better for the member – so they don’t have to fill out another clipboard with the same information; better for the virtual specialty clinician – so they have more context to optimize and maximize the time spent with the member.   


When you’re looking for new ways to improve member experience and truly move the needle on empowering members to engage in their own health, consider a virtual specialty care model. Find out more here.