People and Data: Key to Member Experience Transformation

In an era of rapid technological advancement, healthcare organizations are struggling to keep up. With the constant emergence of AI, GenAI, and agentic AI, navigating digital transformation is a significant challenge. Transformation is essential for health plans to lower costs and, most importantly, improve the member experience, particularly in the critical area of behavioral health.

While the reason why transformation is easier to discern, the “how” is more difficult to ascertain and integrate effectively without expert guidance on the best ways to unite technology and people.

The Behavioral Health Opportunity

Behavioral and mental health challenges represent a constant and growing issue, exacerbated — even now — by the pandemic. According to the National Institute of Mental Health, one in five U.S. adults — 59.3 million people — lived with mental health challenges in 2022. While this number is tragic, health plans have an unprecedented opportunity to help their members address these challenges proactively.

Thankfully, the stigma surrounding mental health has decreased significantly, and people are more willing to discuss these issues. This cultural shift allows healthcare organizations to get ahead of member challenges by creating innovative programs. The starting point for this innovation is technology fueled by data.

Unlocking the Power of Unused Data

Health plans possess an “astounding amount of data” that is largely untapped. The article cites a World Economic Forum statistic that 97% of data produced by hospitals every year is never used. This massive, dormant resource is the key to both retrospective and prospective member interventions.

Guiding health plans in the process of identifying and evaluating this data is the expertise that Sagility has honed for over twenty-five years. Predictive models can enable the creation of new mental health programs. This kind of exploration is vital for identifying members who may need assistance based on their history.

Agentic AI: A New Frontier in Real-Time Triage

Yet, the most groundbreaking opportunities lie in a prospective approach using agentic AI. Agentic AI is a transformative tool for real-time member interaction. When members engage with the health plan online, Agentic AI can triage them on the spot.

This technology goes beyond simple chatbots. It is designed to be “socially savvy,” integrating AI with emotional intelligence. During an interaction, agentic AI can:

• Analyze tone and mood: It can understand the member’s emotional state from their voice.
• Access data on-the-fly: AI can simultaneously access the member’s claims and health history.

By combining the member’s emotional state with their clinical data in real-time, AI can effectively triage their needs as they are communicating. This creates the potential for a “virtual intake channel” that can instantly classify a member’s needs, schedule a doctor visit, or execute a warm transfer to a healthcare provider.

This interplay between technology and behavioral health can directly address the ongoing nurse shortage while simultaneously increasing the number of members receiving timely mental health care. By identifying and acting on mental health issues early, health plans can drive down long-term healthcare costs and dramatically improve the member experience.

Uniting People and Technology

Technology in itself is not the ultimate solution. The true transformation comes from uniting siloed programs and departments into a cohesive whole. 

This human-centric implementation involves:

• Creating workflows to get members into the new system quickly.
• Interviewing payers and providers to define the clinical markers that place members into high-, medium-, or low-risk groups.
• Building predictive analytics models to identify who needs assistance.
• Ensuring the seamless integration of internal and external technologies.
• Guiding teams to ensure successful program implementation and supporting change management.

As technology continues to evolve, the opportunity for health plans to maximize its potential will grow. With knowledgeable, healthcare-focused guidance, the complex idea of technology transformation becomes a reality.