PacificSource

Service Design & Research / 2021

Summary

Challenge

PacificSource, a non-profit insurance company based in the Pacific Northwest, wanted to understand better and engage with their Medicare members, especially those with multiple chronic conditions and members in rural areas. They needed to increase engagement with Annual Wellness Visits, a free service that 70% of members didn’t use in the past year. These visits helped them catch health problems early and reduce health costs due to unmanaged chronic conditions, which could run thousands per year.

Context

The company disliked personas and made decisions almost exclusively based on quantitative federal survey data with a two-year lag time. Our cross-functional team of busy clients was also stretched thin across numerous initiatives, which presented challenges in keeping a full team of 15 actively engaged during 8 am check-in meetings. These findings would also inform a 2022 website redesign and digital transformation efforts including improved data collection capabilities.

Outcome

We developed and delivered:

• a 30- to 180-day roadmap & toolkit to reimagine Medicare member engagement

• a member insights book to summarize research findings

• a PowerPoint starter kit to bring critical insights into everyday working processes

• a virtual workshop series and roadmap for a provider pilot partnership with a local community health system to road-test and implement some concepts

We also inspired a member-centered way of working oriented around a deeper understanding of members beyond age groups or clusters of conditions. This provided a solid foundation for them to develop more informed, resonant interventions that saved thousands per member and helped each member achieve better health outcomes so they could live their lives to the fullest.

My Role

Lead Designer, Researcher, and Project Lead with one other researcher and a part-time engagement manager.

Process

Our process combined:

1. Secondary research to understand the broader landscape around Medicare, chronic conditions, wellness visits, and rural health attitudes

2. Analysis of current PacificSource materials including transcripts to understand current organizational practices and approaches

3. Interviews with members, caretakers, and PacificSource to learn more about members’ mindsets and approaches towards health

4. Grounded theory analysis using Atlas.ti

5. Service design to explore potential quick wins, revised communication approaches, and larger-scale service ideas based on our research

6. Concept testing with members around revised materials like flyers

7. A collaborative workshop with a local health system to partner to develop community-level interventions as a service pilot

Research Questions

What does the healthcare journey look like for members with chronic conditions?

What are members’ attitudes and behaviors toward health and any patterns or common themes between them?

Why do & don’t members keep up with preventative care actions like Annual Wellness Visits & managing their conditions?

What unique barriers exist for rural members?

Developing a Foundational Understanding

To drive members toward a specific action (attending an Annual Wellness Visit) and shape long-term behavior change (managing their chronic conditions), we needed to understand more about their unique contexts and motivations. This included:

• Their chronic condition journeys and current management systems - or lack thereof

• Their care ecosystem, encompassing health professionals, caretakers, and pharmaceutical and technological interventions

• Different attitudes and motivations around taking health actions like visiting the doctor, which could vary greatly from condition to condition

• Unique barriers for rural members, who made up 35% of the member base

• Awareness of and attitudes toward current PacificSource interventions like services and outreach materials

Process Challenges

We encountered three main challenges during the process:

Access: We had no direct access to members to interview at the start of the project

Understanding: Our clients were well-versed in quantitative research but new to qualitative design research, and also had an aversion to personas. We also needed to quickly get up to speed on the nuances of the complex Medicare landscape.

Engagement: Our cross-functional client group spanned 15+ people who worked in different departments. Keeping a large team actively engaged during bi-weekly 8 am meetings was critical to gaining accurate insights and feedback early and often. We also needed a way to expand insights beyond the project team to the full organization to ensure they could be truly member-centered in the future.

Challenge #1: Lack of direct access to members

While we worked out the logistics around contacting members directly, we leaned on the organizational expertise of people in member-facing roles. In addition to conducting secondary research, we developed and led group interviews and workshops with customer service & Medicare member support specialists (MSS), collaboratively journey-mapped with Care Managers, and analyzed support call transcripts to start understanding potential attitudes and behaviors.

Challenge #2: Clients new to qualitative member research

Our clients wanted to keep members at the center of their decisions, but wanted an approach besides personas. We learned early on that due to their quant-heavy approach, they were used to thinking about people in broad categories (65+, member with 2+ chronic conditions) and were used to tactical approaches around engagement (”how do we get members to go to Annual Wellness Visits?”). We needed to show the bigger world and context for individual people around their health attitudes and behaviors and reframe prior assumptions, like assuming rural members were not concerned with their health and regularly engaged in less-healthy habits.

During our interview process, we used directed storytelling, a design ethnography method to bring people’s health experiences to life through personal stories instead of generalizations. We also used Indi Young’s Problem Space Research approach, which seeks to understand problems through an individual person’s purpose first rather than first studying them through the lens of a company’s potential solutions. This helped us get to a deeper level get to depth around their inner thinking, reactions, & guiding principles around health decisions that could serve as evergreen research with application beyond the Annual Wellness Visit.

Instead of cherry-picked quotes and highly-produced stock photos, we used member summaries with audio clips and Creative Commons images to illustrate stories in way that felt rich and real and got to the heart of what good health enabled for them. While presenting these stories and clips in meetings, we could see a change in how our team related to people they might previously had only known by their conditions and adherence status, like “2+ chronic conditions, no Annual Wellness Visit in two years”.

To address the aversion to personas (which I agree with), I used Indi Young’s Thinking Styles, a mindset-based approach that describes people in terms of flexible attitudes and behaviors based on context, condition, and health action and avoids fixed assumptions & biases based on demographics, psychographics, and age. For example, someone might always attend their Annual Wellness Visit but avoid their cancer screenings or colonoscopies due to discomfort or fear.

Challenge #3: Engaging a busy 15+ member client team during 8 am meetings

In the first few weeks of the project, we noticed we primarily heard from the same couple of people. We knew we needed to engage the full team not just for our own understanding but to ensure buy-in and adoption of a member-centered approach across the organization. We reformatted our 60- to 90-minute meetings as co-creation sessions, leveraging quiet reflection time before sharing thoughts and answers, breakout rooms, and cloud PowerPoint docs or Miro boards as working spaces, providing space for individual reflection time and group sharing.

Insights

We uncovered rich details throughout the process, but three key insights stood out as high-level guiding ideas we wanted our client team to keep top of mind.

Members need to feel understood as individuals.
Understand them as people, not just care gaps or risk scores. Get curious about what matters most to each member so you can understand what interventions serve them best instead of overwhelming them with calls and irrelevant service offerings.

Health behaviors can be better understood by Thinking Styles.
Members can switch their thinking styles or mindsets between conditions or intervention types, like taking a hardline stance against medications or attending all screenings except for cancer screenings due to fear. We need to design interventions (services & communications) for a variety of thinking styles to achieve better clinical outcomes across the board.

Member health decisions are driven by what matters to them.

Health itself isn’t the reward or end goal: what matters is what good health makes possible in terms of what matters to them. Quality of life goals and activities, which could be as big as maintaining their mountain bike rides or as small as being able to hold their grandkids on their lap, served as a powerful intrinsic motivator to drive members to maintain their health.

Shaping Behavioral Design with the COM-B Model

We used the COM-B behavior change theory and model to help our clients understand the barriers members faced. Our client typically relied on emails and flyers to remind people, but we learned that information alone wasn’t enough: we needed to address other barriers around attitudes, emotions, and logistics.

Thinking Styles: A Comprehensive Health Decision Framework

We used Thinking Styles as a framework to make sense of different approaches to making health decisions. They encompass the inner thinking, reactions, and guiding principles for how people approach their decisions.

Inner thinking: active thought processes & decision-making at a point in time

Reactions: emotion or feeling that causes an action, decision, or thought process at a point in time

Guiding principles: rule or foundational instruction for making decisions

This approach offers four key benefits as a richer, more flexible alternative to personas:

1. Synthesize behavioral, contextual, and conversational clues

2. Describe people in terms of flexible attitudes and behaviors based on context, condition, and health action

3. Avoid fixed assumptions & biases from personas, demographics, & psychographics

4. Support a broader diversity of people

The four mindsets proved more flexible and simpler than trying to segment interventions and communications based on age groups or combinations of conditions. Paired with the COM-B behavior model, we could easily map thinking styles to the barriers to taking health actions and come up with the right interventions for each.

Reshaping Assumptions about Rural Members

We also helped reshape how people viewed rural members. The assumption and picture that came to mind was that rural members were less engaged in health-related activities and more engaged in unhealthy habits.

We found people from rural communities tend to have an independent, do-it-myself attitude, which makes showing vulnerability and accepting help especially challenging on a deeply cultural & ideological level. There’s also a cultural distrust of health systems and sharing information with systems, as well as stigma against treatments and conditions like mental health. This distrust could be exacerbated by the prejudice and bias they experienced while seeking care. However, they had their own approaches to healthcare rooted in interventions outside the mainstream health system which included things like holistic practitioners and natural remedies, both of which were less likely to be covered by their insurance plan.

Solutions & Outputs

Guiding a New Approach: Member Experience Principles

We developed a set of experience principles for PacificSource based on the insights to keep the new learnings top of mind and help them leverage their organization’s strengths. We worked on these iteratively with them to ensure they felt resonant with and true to the organization and felt actionable enough to use effectively when developing services, products, and communications.

A Detailed Reference: Member Insights Book

We created a detailed insights book to cover our core research questions in-depth and organize additional information that came up throughout the process, like the role of caretakers, so we could extend our research learnings to the full organization.

Sections included member summaries, mini-stories from our members with audio clips from interviews to help bring the concepts to life; reflection questions for teams to apply learnings to their work; and graphic visualizations where possible to make processes and systems more visual. Select slides are included below and the full insights book can be found here.

Reimagining Member Engagement: Concepts to Test

Together with the client team, we developed service, product, and communications concepts and ranked them by their level of complexity to inform the roadmap and toolkit and inspire the team with potential ideas.

Bringing Research into Everyday Practice: Insights Starter Kit

We knew teams would need an easy way to bring high-level insights into their daily work with people who hadn’t seen the full research book. We created a Health Action Starter kit, a short 12-page PowerPoint that brought out the most salient insights and experience principles to keep members at the center when developing new services, products, and outreach materials. It could easily fit into existing templates and slide decks, making it seamless for teams to use in any other plan or presentation.

Plans & Tools to Reach Future Experience Visions: Roadmap & Toolkit

We used our research findings to develop a comprehensive toolkit and roadmap outlining actions that could be taken between 30 to 180 days, as well as thought-starters around other areas we discovered through our research like support for caretakers.

Impact

We sparked seeds of organizational change at PacificSource to help them focus their efforts on supporting members as individuals and enabled them with the right resources and tools to do so. By looking past classifiers like demographics or risk scores for chronic conditions, our client avoided assumptions and better served their members. We also made plans to present the findings to and train other people at the organization on how to use the resources we created.

We also built excitement for new research efforts and kicked off a new way of working with their local health system partners through a provider partnership pilot workshop we led (details here).

Key Learnings

With free rein to move beyond personas, I leaned into Indi Young’s Problem Space Research methodology to reach a greater depth of understanding. It focuses on listening to people through the lens of their purpose first, rather than in relationship to the product or service your organization wants them to use, and produces evergreen insights that are flexible and durable. I also used behavior change design and referenced the book Engaged: Design for Behavior Change as a key resource throughout the process.