The Member Behavior Gap
Why health plan design doesn’t always change care choices — and what employers can do about it.
The Core Problem: Good Plans, Unchanged Behavior
Employers put a lot of effort into health benefits, assuming better plans will lead to better choices. But members often keep using care the same way they always have.
Lower costs, easier tools, and clearer rewards do not always change behavior. People still choose based on habit, convenience, trust, and urgency.
Plan design focuses on
Coverage, cost, networks, incentives
Members decide based on
Convenience, trust, urgency, habit
Why Plans Don't Change Behavior: Incentives, Defaults & Complexity
Many benefit designs rely on incentives — like lower copays for urgent care or rewards for generic drugs. The idea is simple: make the right choice cheaper, and more people will choose it.
But people usually respond more to convenience, trust, and habit than to price alone.
Doctor Recommendation
If a doctor points a member to a provider, they usually go there.
Perceived Quality
People often stick with familiar health systems because they seem better.
Fast Access
Members usually choose the option they can get into sooner.
Past Experience
Good or bad past visits shape future choices.
The Default Path Problem
Most members follow the same care path every time: their PCP refers them, they follow the referral, and the habit sticks. By then, plan design has little effect.
That is why lower-cost alternatives often go unused, even when they work just as well.
Complexity Creates Friction
Complicated networks, tiers, and rules do not usually change behavior. They often just make decisions harder and push people toward the easiest option.
The Role of Trust in Healthcare Decisions
Healthcare decisions are personal. People usually trust a doctor, not a health plan.
First Visit
A member picks a doctor.
Ongoing Care
Regular visits build trust.
Physician Referral
The doctor recommends a specialist.
Loyalty Locked In
The habit is set.
Where Plans Overestimate Their Own Influence
By the time a health plan's tools kick in, the key care decisions are usually already made. The member has chosen a doctor, the doctor has made a referral, and the appointment is set. At that point, the plan is mostly just processing the claim.
Plans often think they can steer the most expensive decisions. In reality, their influence is much smaller than they assume.
What Actually Moves Member Behavior
Member behavior can change, but only with the right approach. Research and payer data show that a few simple factors make the biggest difference.
Timing and structure matter more than incentives alone. The right help at the moment a decision is made works better than a reward offered later.
Reframing the Strategy
The old question is: "How do we build a better plan?" That still matters, but it is not enough.
The better question is: "How do we shape decisions when they happen?" This means focusing on the moment of choice — not just the plan document.
1
From: Plan Design
Build coverage and incentives, then hope members respond later.
2
To: Decision-Moment Strategy
Use navigation, provider support, and real-time guidance to shape choices now.
This works best when plan design, navigation, provider alignment, and member touchpoints all work together.
Let's Connect
Health plan results depend on the decisions people make in the moment.
When members, providers, and plan design are not aligned, even strong strategies can miss the mark.
Finding that gap is the first step to better cost and care results.
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