5 Guiding Principles for Health Care Exchange UX

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August 1, 2014

Ever since health insurance made its U.S. debut in 1850 (as insurance against railroad and steamboat accidents), the topic has been fiercely polarizing. Failed reforms proposed by presidents Truman, Nixon, and Clinton — and the passage and rollout of the Affordable Care Act (ACA) – have each been hyper-controversial.

But if there’s one thing everyone can agree on, it’s that health insurance – getting it, using it, paying for it – has never been “user-friendly”.

But, that may be changing.

For better or worse, health care exchanges have arrived and are here to stay – and they are changing the way consumers understand and select health insurance. In our work developing user experiences for private exchanges, we’ve identified 5 guiding principles that we believe will help promote informed and positive consumer experiences.

In this article, we’ll provide an overview of these 5 guiding principles. In future articles, we’ll detail some specific user experience design patterns and choices that can be used to ensure success when designing these type of experiences.


First, What Is a Health Care Exchange?

A health care exchange is a way to offer health insurance that provides consumers with several options from which they can select the plan that best fits their needs. Exchanges reduce costs and administrative burdens and put more control in the hands of consumers. The government runs public exchanges and privately held companies run private exchanges. In short, it’s about giving people choices.

Despite its botched website rollout last year (to be clear – that wasn’t us!), the ACA enrolled approximately 8 million people on its public exchanges.

Meanwhile, a surprisingly large number of people – approximately 3 million – enrolled via private exchanges as well. And the number of enrollees on private exchanges is expected to explode to 40 million by 2018.

Private Exchange: Projected  to grow from 3 million enrolled in 2014 to 40 million enrolled in 2018

Our Experience with Health Care Exchanges

The annual cycle of health insurance enrollment is a major factor when it comes to any employer-provided health care. With a new and rapidly changing product like Health Care Exchanges – enhancements and launches typically occur in a very tight time frame. There are often mere weeks between project kickoff and technical hand-off. We feel strongly that our small size and collaborative approach are crucial – it allows us to move forward with confidence and clarity. And our clients trust our expertise based on our proven track record.

Crux Collaborative began work on very early private exchange systems in 2011. Since then, we have collaborated with our clients to design private exchanges for some of the world’s largest companies. Thankfully, the exchanges we’ve worked on did not have the same issues as In fact, the biggest private exchange we worked received a > 90% customer satisfaction rating in post-enrollment surveys. The reason is simple: collaboration. We collaborate at every step of the process with our clients, with their vendors, and with end-users to design systems that are effective because they consider the objectives and needs of all constituents.

Since health care exchanges are centered on web functionality, we collaborate with our clients on strategy, program design, experience design and everything in between. Each year, we conduct usability tests at our Minneapolis facility and around the country – then leverage the findings to match user needs and our clients’ business objectives. We create and conduct usability studies with semi-functioning prototypes – then repurpose them as clickable guides for portal developers.

5 Guiding Principles to Follow

We’ve identified 5 guiding principles to follow when designing today’s health care exchanges. We expect exchanges to evolve quickly – and this list will too.

1. Educate

It is critical to educate users to a new way of thinking about health insurance. Exchanges separate the idea of a “health plan” from the insurance company, or “carrier.”

Not many consumer decisions work this way – so it can be challenging. Imagine if all cellular phone companies offered the same basic options (number of minute, etc.) for a few plan levels (Gold plan, Silver plan, and Bronze plan). Once you picked your plan, you’d then need to decide if you wanted Sprint, Verizon or AT&T.

This is a significant change from the way choices were made before healthcare exchanges existed. The type of plan used to dictate the carrier – but that is no longer the case. For consumers, this change can be very confusing – akin being asked to pick the type of cuisine after you’ve picked the restaurant. Consumers often assume that if they pick a plan type, they’ve picked the carrier as well, and this is no longer the case.

Making sure users understand this paradigm is critical to your success. It needs to be clear that there are multiple choices to make. From a user experience standpoint, we rely on visual cues, carefully tuned layouts and precise language. During pre-enrollment season, we allow users to learn about what it’s like to enroll.

2. Define

People make decisions in very different ways and we’ve found that “one size fits all” does not equate to success in health care exchanges. We have discovered that defining personas can help tremendously.

Healthcare purchase decision-making is similar to decision-making when it comes to other major purchases.  Some people go into a car dealership knowing the make, model, year, style, and accessories they want. Others go in wanting to learn about the different types of vehicles and any significant changes and improvements to the upcoming model year vehicles. It’s important to design an experience that accommodates multiple decision-making styles.

Our usability studies have not only confirmed that users are able to understand the process better when the experience matches their stage in the process – but also that matching the experience to the appropriate persona results in users who are noticeably delighted at ease of the process.

Identifying the right personas for the experience and ensuring that there is a meaningful experience and path for each persona is a critical part of the user experience strategy and planning process.

3. Empower

Users in 2014 expect to have tools available to figure things out on their own – and companies and organizations can no longer afford to staff for 1-on-1 HR intervention for every health care enrollment. For example, a consumer expects to be able to look up whether their doctor is within the networks they need to choose between.

Decision support tools at key points in the process are critical. And ensuring that the right tool is presented at the right time is a key factor. There are points when consumers are gathering information and need to be able to do so easily and simply. There are also points that they are comparing options, and the tools to accommodate this objective can be more complex in both content and functionality.

But it is critical to offer the right tools at the right time in health care exchanges. A delicate balance must be achieved between guiding the user and empowering the user. Too much information or poorly considered design could leave users confused and frustrated.

Validating the type of tool and the placement and availability of tools in the interface is a primary objective in prototype usability testing. Organizations can learn a lot, correct mistakes, and save significant development costs by conducting prototype usability as a design step when creating decision support tools.

4. Restrain

You may be tempted to answer all of the various users’ questions at once; or to assume that providing answers to every possible question at every step of the experience is helpful for consumers. We’ve learned it is important to restrain ourselves from attempting to do too much – and instead, keep users focused on one clear purpose per screen.

When users are able to make steady progress and feel comfortable with their choices, they take no issue with experiences that take longer. A common misconception is that a user experience is better if it “reduces clicks” when in fact, the exact opposite can be true when it comes to infrequent and important interactions, such as major purchases. Our usability studies have shown that consumers recognize the need to take time and make the right choice. They overwhelmingly value the feeling of confidence that arises from a well-informed decision over speed of task completion when it comes to these types of user experiences.

In helping organizations achieve these user experience objectives, we’ve developed systems that include inline and contextual help, as well as “escape hatches” for users who need more information. We’ve also learned to not sacrifice simplicity for the many in order to answer questions for the few – or to accommodate fringe cases at the expense of the broader experiences.

5. Evolve

Each cycle brings with it mountains of new analytics data, new research findings, changes to the law, emerging trends, and updates to programs and product offerings. Collaborating with your clients to make sense of all this as early as possible helps propel you into the next year’s cycle of updates and prepare you to succeed.

Developing a plan that doesn’t end with a release but identifies how to incorporate enhancements and new features into the next iteration of a product is key to ensuring long-term success with products such as health care exchanges that are rapidly evolving to meet marketplace evolution and demand.

The landscape of health care exchanges will continually bring surprises and challenges as it expands – but we are excited about the opportunity to keep improving the experience of choosing one’s health insurance.

Perhaps one day soon, rather than a confusing and frustrating headache, selecting your insurance will be viewed as a simple process that empowers you and educates you on ways to live healthier and  save a few dollars.

If you are interested in learning more about how we help companies to design complex, transactional, data-driven user experiences such as healthcare exchanges – please contact us. We look forward to collaborating with you to create a user experience that will meet your business objectives while delighting your users.

By Mahtab Rezai
Principal & CEO

Mahtab has spent nearly two decades as a user experience designer, researcher, strategist, leader, and mentor. She has designed user experiences for companies ranging from startups to the Fortune 50.

View Mahtab's Bio

By Tony Johnson
Senior Front-end Developer

Tony has spent well over a decade building interactive applications. He collaborates in the full life cycle of projects – bringing a unique blend of technical savvy, creativity and strategic thinking to our user experience consulting services.

View Tony's Bio


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