Inefficient Processes Stifle Creativity and Continuous Improvements

Whether it is value-based benefits, episodes of care, or evolving state and federal regulations—without the right technology, health plans will struggle to keep up with trends and changes in the industry. These challenges only intensify for smaller health plans with limited resources and less margin for error.

To remain competitive in today’s market, health plans must have the ability to stand up new lines of business and benefit plans quickly and efficiently.

For many payers, bringing a new product or benefit to market often requires significant time and resources. For health plans using older core administration systems, configuring a new benefit plan involves the claims department working with the IT department to explain the benefits and what’s covered, conduct testing, identify errors, and find solutions.

This back-and-forth process, which can take months to complete, occurs while members are already utilizing the benefits. Health plans are pressured to get payments out of the door, accurately and efficiently. Still, they cannot process claims against a benefit that is not yet configured in their system, resulting in processing claims incorrectly until the benefit is placed into production.

Health plans must then handle the backlog of incorrect claims. This workload requires IT and claims resources to run a report with hours spent working to identify what was impacted by this benefit plan and running backouts and re-processing the claims to get everything in sync.

With so many steps and so much ground to cover, this cumbersome process often causes IT departments to become bloated. The IT resources are highly-skilled and know the technology well, but they do not necessarily know the business or understand the benefits, leading to more potential errors and inefficiencies.

With the immense time and resources spent on deploying one benefit plan, how can health plans react to shifting consumer behaviors and the evolving healthcare landscape and quickly go-to-market? Health plans need a flexible system that allows them to test and implement those benefit designs in a timely manner so they can focus on making continuous improvements that attract and retain their members and drive success in their business.

Health Plans Must Prioritize Member Satisfaction

Gone are the days of the traditional, slow, steady insurance business. Welcome the next generation of health insurance, where plans must be fast and agile to please their members.

Today, health plan consumers are empowered, informed and demand more sophisticated, convenient, transparent, affordable, accountable, and personalized service.

Health plans must shift their business models to embrace empowered consumers by consistently offering the best, most competitive services, and benefits.

This approach requires payers to invest technology that supports the introduction of new services and products and do so at the consumer’s speed, in a manner that meets the consumer’s needs.

Does your system make it difficult for you to create a new plan or benefit change? Sometimes it can take six to nine months to complete these updates in the system in time for enrollment. Do these changes require highly-skilled IT professionals? Oftentimes, these changes can take resources and hours away from other valuable projects for an organization. And even then, with all of this time and effort, it’s not guaranteed that it will be successful.

For today’s consumer, and tomorrow’s success, health plans need technology that enables them to make changes to plans and benefits in a matter of hours. This capability pleases members and providers alike by providing access to accurate information in a timely manner.

Does your system allow users to see information in real-time? Baby Boomers, Gen Xers, and Millenials are demanding transparency and access to accurate real-time information available to them 24/7 through a variety of channels.  This means layering the digital information era on top of the traditional health insurance infrastructure in a way that allows your organization to quickly respond to market demand and be the first to offer the most up-to-date, innovative plans.

Don’t Fear Change, Build a Culture of Continual Optimization

Health plans that implemented a core administration system twenty years ago and have only taken technical upgrades for two decades struggle to efficiently operate in today’s market. The failure to design their processes around flexibility to adopt the enhancements delivered to them over the years puts health plans at a competitive disadvantage.

And while the system may look better today, it’s not performing any differently than it did in the ’90s. Furthermore, the health plan is not getting any value from the additional code they are paying for in their maintenance and licensing agreements.

CTOs and CIOs in this situation must ask themselves:

–         Why is your organization operating the same way as you did 20 years ago?

–         Why aren’t you taking advantage of any new enhancements?

The typical answer is that the time and cost associated with implementing the enhancement and learning how to use the new solution are too high.  Change is expensive unless we build a culture of continual optimization.

At some point, if payers simply let business users run the core administration system without focusing on the outcome of why they execute a certain process, it will result in “paving the cow path” and they ultimately just achieve inefficiency faster in a better-looking system.

Enhancements and upgrades add value, give health plans a competitive advantage, and allow organizations to operate more cost-effectively. Health plans must have the ability to adopt enhancements, have confidence they will work, and the flexibility to build on those functions and align their strategy to the Product Roadmap.

It comes down to whether a health plan has the culture that will continually take enhancements and not find themselves painted into that box twenty years later, wondering how they let so much time slip by.

I’ve seen this happen to numerous organizations, and I wonder what led them down this road? A health plan can look at a timeline of all the different versions of enhancements and upgrades that they ignored and correlate these milestones with potential opportunities they missed that could have advanced their business. Even though they had all the tools, answers, training, and resources at their fingertips, they just were not open to changing what they already knew and updating the way they operate.

For health plans that fear change, my advice is to embrace the upgrades that feed into continual optimization processes and allow your organization to make progress in the future.

Focused on Innovation? Start with Operational Efficiency

For health plans, operational efficiency could be the first step in their approach to innovation. While it may not be the most exciting aspect of the business, achieving operational efficiency will enable them to remain competitive in the long-term.

A health plan can have the most innovative ideas in the world, but without the resources to back it up, they most likely will not get very far. Operational efficiency, automation, and accuracy free an organization to focus on innovation. By prioritizing operational efficiency, organizations can redeploy the time and resources typically spent on routine  administrative tasks, and shift to transformative projects.

Flexibility and agility are also incredibly important. A health plan with great ideas for new market-competitive products that advance the organization’s innovation goals requires the technology flexibility to configure and automate them, along with the ability to make changes quickly. Otherwise, they will end up losing momentum and missing out on crucial business opportunities.

Health plan innovation touches many aspects of the organization, including member engagement, payer-provider collaboration, and business processes, and in many cases, impacts benefit designs, provider contract designs, and other aspects that help drive behavior. To remain competitive, health plans must have the freedom to test new ideas, try modeling, make mistakes, and access their data in real-time to see what works and continue improving.

When it comes to implementing innovative ideas, a core administration system that breaks down product design barriers, increases efficiency, and delivers real-time transparency is a necessity. If the majority of an organization’s ecosystem is cutting-edge, but the core administration platform is outdated, everything else will fall behind. Healthcare moves fast, and health plans need the ability to be forward-thinking.

All of the health plans I talk to have incredibly innovative ideas. They want to invest in a meaningful member experience, they want to enhance payer-provider collaboration, and they want to transform their organizations. To achieve these goals, they need a system that empowers them to focus their skills, experience, and capabilities on actively impacting the true health of their individual members and the U.S. healthcare system as a whole.

Speed to Market with New Business Models Drives Competitive Advantage

Health plans must add or expand new business models quickly to take advantage of opportunities, drive competitive advantage, and retain membership. All health plans, no matter the size, continually address their business plans by expanding into new geographical markets, creating new products, marketing to new customers, or simply retaining membership by building satisfaction and loyalty. But to do it successfully, they must be able to answer the following questions before they launch:

  • What benefit offerings will resonate with the market?
  • How can the retention rate for existing business be improved?
  • Will the group/member setup be completed on-time with high quality for processing?
  • Does the provider community properly support improved health and low cost to the members?

In the years I’ve spent working directly with our customers, I’ve learned a lot about what they are worried about, what challenges they’re facing, and what keeps them up at night. While working with large regional health plans, here are some of the scenarios I’ve witnessed:

A regional Northeast health plan with Commercial, Self-Funded, Medicare Advantage, and Medicaid lines of business, added new provider contract and payment models, and implemented value-based payments, to align with the provider network. By doing this, they increased customer satisfaction and overall health in the community, as well as improved stakeholder engagement among members, employers, providers, and hospitals.

A Mid-West organization with Commercial, Individual, Medicare Advantage, and Medicaid lines of business, focused on speed-to-market and decreased time to create and launch a new benefit plan. As a result, they increased member satisfaction by simplifying account setup and enrollment and reducing errors.

Several customers have had to respond to providers and consumers embracing new care by offering patients a hybrid of telehealth and physical visits and enhanced mental health resources. With multiple options to deliver and receive quality, convenient care, it’s important that health plans design benefit plans that address consumers’ needs.

When all is said and done, I’ve come to realize that maintaining flexibility and the ability to respond quickly and correctly the first time not only enhances a payer’s competitive position but, in many cases, can save a regional plan. It has become binary. Have the ability and succeed, or not build the capability and fail. Happily, I’ve seen many chose to succeed.

Getting Back to Care

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A group of 11 payers, providers, and healthcare organizations recently launched an ad campaign to encourage patients to stop “medical distancing” and seek care.

“We are seeing a troubling pattern that people are avoiding medical visits in fear of contracting COVID-19,” Humana’s Chief Medical Officer of Humana, William Shrank, M.D. said in a statement. “While we understand the fears that many people have around contracting the virus, our country’s medical facilities have adopted CDC guidelines and best practices and even telemedicine options to make your visit as safe as possible to prevent the spread of the virus. The intent of the campaign is to let people know that protecting yourself against getting this virus does not need to come at the expense of your overall health.”

Getting back to care is critical for everyone

As our nation worked to flatten the curve, states were required to halt surgical and elective procedures to ensure they had the capacity and enough PPE to treat a possible surge COVID-19 patients, as well as taking necessary precautions not to spread the virus.

A report from Health Affairs found that in-person patient visits were down 69% in March and April. And, the CDC reported that emergency room visits dropped more than 40% in April. A recent study showed that pediatricians, pulmonologists, and various surgical specialties saw the most significant decline in visits, with pediatricians seeing the most substantial gap with visits 34% below pre-pandemic levels. Cancer screenings reduced by 94%, and medical imaging decreased by 50% compared to the past three-year average.

While more states begin lifting these bans, providers are struggling to recoup their losses from the spring, while working in a new normal.

Researchers have projected loss of nearly $68,000 in fee-for-service revenue per physician for 2020 and estimated $15 billion losses to primary care practices across the country over the calendar year. Furthermore, the American Hospital Association’s June survey of 1,360 hospitals in 48 different states found 67% of respondents do not foresee their health system returning to baseline volumes by the end of 2020, and 30% reported the timeframe was unknown. Based on their findings, The American Hospital Association estimates hospitals and health systems will lose at least $323.1 billion in 2020.

Providers are encouraging patients to get back to care. While visit numbers have started to rebound, they remain significantly lower from pre-pandemic levels as patients are reluctant to return to a healthcare setting.

While decreased patient volumes translate directly to a loss in revenue for providers, this trend will also harm patient care. Without seeking preventative care, testing, and delaying vaccines, patients could miss a critical diagnosis or life-saving treatment, leading to higher costs and worse overall health outcomes in the long term.


How are health plans are adapting, responding, and addressing changes during the COVID-19 pandemic?

Download the issue brief to learn how HealthEdge customers addressing business needs, adjusting their budgets, and ensuring providers get paid while simultaneously keeping their organizations running smoothly in a new work environment.





Hospitals, providers, and health systems are taking measures to support consumer confidence

For providers to begin to return to normal volumes, patients must feel safe and comfortable visiting a health care setting.

Providers across the country have invested in new safety protocols and training, including enhanced sanitizing and infection control procedures. Tasks as simple as scheduling appointments must be strategic, so waiting rooms can adhere to social distancing guidelines. Now, more than ever, providers must focus on adapting to patient needs and improving patient satisfaction.

In an interview with Becker’s Hospital Review, Cleveland Clinic CIO Matthew Kull said, “Embracing change is going to be critical for everyone. The same old way of doing things is probably not going to be the path forward. The adoption of digital technologies across healthcare accelerated four or five years as a result of COVID, and we’re not going back…we have to look at normal in a way that is going to help us reach more patients the way they are going to want to be connected with.”

How health plans are supporting getting back to care

Specifically, payers have the power to make a significant difference in what the future looks like for the healthcare industry. Providers, payers, and other healthcare organizations must work together to ensure this “new normal” puts patients’ needs first.

Before the pandemic, healthcare was reluctant to change care models. There now has been a willingness to embrace technology across the healthcare ecosystem, providing patients and providers with a hybrid of telehealth and physical visits, with multiple options to deliver and receive quality, convenient care.

Insurers require flexibility to design benefit offerings that meet their members’ needs, support their providers, and remain compliant with shifting government regulations.

With HealthRules® Payor, health plans can design and implement any benefit plan or provider contract in less time and at a lower cost than typically required with other systems. The ability to successfully embrace change gives HealthEdge customers a competitive advantage.  HealthEdge offers unparalleled flexibility that allows our customers to effectively respond, maintain business continuity, innovate, improve their offerings, and help everyone get back to care for the benefit of their members and providers.

Interested in learning more about HealthEdge? Contact Janet Barros to schedule a 15-minute introductory call and discuss your business opportunities and challenges.