Healthcare: Transforming to meet changing consumer expectations

Carol Everhart,

Lessons learned from the 2019 Pega Healthcare Customer Engagement Summit: Industry leaders recognize that the consumer has changed and healthcare needs to change as well

Kelli Bravo, Pega’s Vice President of Healthcare and Life Sciences, welcomed more than 500 industry professionals to the 2019 Healthcare Customer Engagement Summit with a call to action to work together to change how healthcare is delivered around the world. To better serve consumers, the healthcare industry as a whole needs to transform to provide a personalized and responsive experience. In essence, the industry needs to move to a new model for delivering value-based experiences that are individualized, proactive, transparent, and support service and care together.

Driving the need for this change are demands of the healthcare consumer. They expect service that is fast and personalized – with digital apps, instant claims settlements, transparency, and advocacy. But navigating the healthcare system itself can be complicated and frustrating. On top of that, according to Accenture, 33% of U.S. health consumers have no experience with healthcare systems and struggle to make informed decisions. Industry leaders understand this. Every presenter at this year’s summit identified the shift in consumer (and staff) expectations as important, as well as the cost-efficiencies related to improving customer service and navigation through the healthcare system overall. Organizations are motivated to improve operations and engagement to provide a better experience. But the challenges of siloed health networks, privacy, data transparency, pricing, and authorizations can make it difficult for healthcare and life sciences firms to decide which systems and processes to transform first.

Adding urgency to this transformation, Pega’s Founder and CEO, Alan Trefler, pointed out that organizations not only need to evolve from reactive to proactive service, but should also be moving towards preemptive service. “How do we make it so we take the information about what we’ve done today, the interactions that we will be having with healthy and sick people who we need to be providing care for, and tie that to emerging data sources around the genome, around populations of health – how do we make it so on an end-to-end basis we are terrific at every element of this healthcare continuum? … How do we add value to people’s lives?”

One place to begin, according to Alan, is by identifying and closing the digital gaps in internal systems and data. Organizations should start at the heart of their business, identifying the most important care outcomes and microjourneys that need to be improved first, then work collaboratively and iteratively to update these mission-critical processes. Omni-channel capabilities, robotics, and a centralized brain can help organizations break down the silos created by channels and devices, while case management and intelligent automation help streamline processes across systems and drive outcomes from end to end. By taking a design thinking approach that focuses on microjourneys, personas, roles, data, and interfaces, healthcare and life sciences organizations can simplify the implementation and evolution of new applications and technologies to better serve consumers.

How social determinants of health are driving innovative benefits design

Susan Taylor, Pega’s Vice President of Payer Core Administration, took the stage to introduce the topic of consumer value-driven healthcare and speaker Steven E. Goldberg, MD, MBA. As the Vice President of Medical Affairs and Population Health, and Chief Health Officer for Health and Wellness at Quest Diagnostics, Steven is responsible for driving value for Quest’s 60,000 members. He shared his experiences with applying social determinants of health (SDoH) data to digital strategies as part of a “Triple Aim” approach to engage consumers to help improve their experience, improve population health, and bend cost trends.

SDoH attributes include economic stability, neighborhood and environment, health and healthcare, social and community context, and education. They factor in information like literacy, access to clean water, and safe and clean housing on an individual level to help calculate the potential link to a person’s healthcare risk and chronic disease and shed light on potential opportunities to mitigate these risks. Though in the early stages, this next dimension of data has great potential to help improve care and cost-efficiencies.

And costs are important to the both consumer and the provider. The Kaiser Family Foundation reports that cost is the single most important health insurance issue among employees with employer sponsored plans, and more than half of consumers today are putting off care because of cost. Healthcare plan deductibles have gone up 212% over the past 10 years, but wages have only risen 26%. Meanwhile, consumer-directed health plans have increased by over 70% in just the past five years. Steven asked the audience: “As we create a higher cost burden for employees, what is the consequence to individual decision-making regarding access and care, and how can we collectively do something about it?”

His organization is seeing successes through C-suite collaboration on systems that support proactive engagement, getting the right person the right care at the right time. For example, encouraging participation in health screenings and automatically triggering alerts and follow-ups with patients whose results indicate potential risks; creating pathways to allow patients to talk to physicians; and early engagement of impactable conditions. Steven sees the benefit of applications that can analyze SDoH data, clinical data, claims, and personal health information together to identify gaps in care and define actions to take. He also cited as important the development of two-way web apps that allow patients to see these potential gaps in care.

Joining Steven on stage as part of the discussion, Susan added that “the value of engagement to drive the activation of programs can really be beneficial.” Over the course of an individual’s life, health status or barriers to good health can change, which is why systems that can use data to target interventions are important. A responsive benefits system that can analyze multiple sources of data, take these factors into account, and can automatically adjudicate services will help drive more individualized healthcare.

Panel discussion: How consumerism in healthcare is impacting operations, profitability, and consumer choice

A 2019 Pega healthcare consumer study found that only 21% of providers and payer organizations strongly believe patients would switch providers or payer organizations due to poor communication or engagement. However 78% of patients surveyed said they would switch for these reasons. These statistics reflect the changing nature of the healthcare consumer and illustrate the important link between the way organizations engage with consumers and consumer choices. With this as a backdrop, Kelli Bravo teed up a panel of diverse healthcare leaders to discuss how consumerism is impacting the digital and business transformation of healthcare organizations.

These leaders, who are experts in consumer engagement and digital technologies for the healthcare and life sciences industries, dove into the topic further, agreeing that technology is outpacing the legacy systems that organizations have in place and that the industry overall has work to do. Steve Chambers, GM and VP of Patient Access Solutions for Sutter Health, called out the importance of engagement in these industries: “… in healthcare you’re dealing with one end of the spectrum – what is typically the happiest event in somebody’s life – to the most tragic event in a loved one’s life ... and that brings a different level of complexity that we have to address as we’re talking about engagement.”

Norman Wright, EVP and Chief Customer Officer at Optum, pointed out the way measurement of patient engagement has shifted. “We used to measure engagement by ‘Have they been in contact with us?’ and that’s not nearly enough. It’s, ‘Are they truly owning and embracing whatever path that they’re on?’”

Healthcare and life sciences organizations understand the shift toward consumerism and are changing to better engage with consumers to meet their needs. For example, Tom Russell, Director of Claims and Benefits Product Strategy at NASCO, cited how they are improving interoperability with handhelds and wearable devices. They’re also using AI to help make benefit-appropriate advisories to members who call in, then use that info in the right context to better connect with that person the next time the member interacts with the organization.

Fabrice Bocquillon, VP of Information Technology and Solutions for Sanofi’s Integrated Patient Care and Market Access, added that engagement is shifting for two reasons. First, the complexity of the journey – the need to manage many different aspects of treatment and communicate with multiple providers; the second is consumerism. “There has been a shift in the balance of powers.” Consumers are using smart technologies to search for information, and that exposure to more information in turn creates greater complexity in the consumer’s journey. Information is also empowering financial aspects of care and treatment – think purchasing treatment that is the most “bang for the buck” – which is changing the way organizations need to engage with consumers.

On the topic of technologies that are being incorporated to support improved engagement, the panel mentioned digital devices for more connected experiences and APIs to connect channels and data in real-time. As Fabrice points out, digital strategies are still emerging organically as technologies continue to evolve, but even with all the data and information that is becoming available the goal should be to simplify the journey for the consumer. Norman added, the advancements in AI and machine learning will also move the industry forward, allowing providers and service representatives to spend less time on administrative concerns and more time engaging with consumers and focusing on better delivery of care.

Kelli closed out the panel by asking those in the audience to “work more closely together to drive the changes in healthcare that we all expect and need to occur to deliver better business and health outcomes.”

Learn More

  • Watch all of the 2019 Healthcare Customer Engagement Summit replays.
  • Discover how Pega for Healthcare is helping payers, providers, benefit managers, government agencies, and life sciences organizations improve engagement and health outcomes.
  • Read Kelli Bravo’s blog to learn more about how consumerism is driving transformation in health engagement.
  • Join us at PegaWorld iNspire to learn how the world’s leading organizations are leveraging Pega to personalize consumer experiences and accelerate outcomes.


  • Industry: Healthcare
  • Topic: Customer Service
  • Challenge: Customer Service
  • Challenge: Operational Excellence

About the Author

As an Industry Principal for Healthcare at Pega, Carol Everhart applies her decades of experience in healthcare administration and practical knowledge as a Registered Nurse to help healthcare and life sciences organizations streamline operations and deliver more personalized member engagement.