Month: April 2021

A key variable in optimizing IT investment is the willingness and capacity to transform complex business processes and organizational structure. In short, the thoughtful identification of transformation objectives (and inclusion of well-defined measures from which to assess the transformation “progress”) is essential in measuring complex project success.

Accenture recently conducted a global survey of nearly 6,500 business and IT executives worldwide to gain insights into key business goals and priorities for technology investments. As Accenture’s top technology trends for 2021 report stated, “Big changes today require bold leadership—and prioritizing tech. And it’s not just about fixing the business but upending convention and creating a new vision for the future.”

An enterprise application, like a well-architected core system, for example, offers an enabling force for health plan transformation. In most cases, the opportunities are almost infinite – the real challenge is quantifying (and then prioritizing) which activities will net the most effective outcomes.

While health plan organization structure and its business process can many times be challenging, some basic building block measures can help to reduce (what is many times) self-inflicted complexity.

Prior to the actual procurement and implementation of a new core application, these steps include:

1. Setting quantifiable success expectations and goals to be realized from the investment
2. Confirming that business requirements align with those goals
3. Identifying transformation opportunities to leverage investment
   •  Foundational transformation (e.g., overall organizational structure, normalized contractual arrangements)
   • Transactional transformation (more efficient process flow, e.g., claims, enrollment, billing)
4. Configuring and integrating the investment that supports the transformed environment
5. Educating/training all key stakeholders

Competitive market forces and compliance and regulatory demands will continue unabated. The opportunity to effectively address these market challenges through enabling technical architecture and leveraged transformation is there for the taking.

The healthcare industry is striving to successfully leverage digital technologies to create more intelligent and responsive products and services, improve experiences, and increase the speed at which they operate. The pace of digital disruption in healthcare is not slowing down. To adapt as fast as the industry transforms, payers must embrace these 10 tactics or they risk falling behind.

1. Modernization Strategy

The accelerated pace of digital disruption in healthcare is forcing payers to double down on their administrative modernization efforts. To remain competitive, payers must consider how they operate today and how they will meet tomorrow’s shifting market demands. Without a clear strategy, payers risk wasting time and money building or investing in solutions that provide a quick fix for immediate needs but are not designed to support the future of digital health.

2. Next-Generation Solutions

Digital technology startups in the healthcare space are utilizing cloud-computing, shared data hubs, API capabilities, artificial intelligence, virtual and telehealth, remote monitoring, mobile apps, and more to improve care, lower costs, and advance medicine. They are distributing information across a broader swath of solutions and a wider set of players. Healthcare delivery has sped up from months to weeks, to days, hours, minutes, and even seconds, putting tremendous pressure on payers and providers to invest in next-generation technology or get left behind.

3. Accelerate and Encourage Digital Adoption

Advancing to differing degrees and at different speeds, the digital adoption occurring across the health ecosystem has caused a cacophony of dissonant architectures jamming up the flow of information and introducing discord amongst stakeholders. While one end of the business is making decisions in real-time, the other end is stuck, dealing with the gaps and misfires resulting from latent data and delayed processes and payments. With legacy systems and outdated technology, the quality of care suffers, backlogs pile up, and opportunities to support new innovations evaporate.

4. Flexibility 

Flipping from legacy to next-gen is a daunting effort. Where to begin, when to proceed, and how to shift to digital while managing daily operations are questions in need of clear answers. The industry will continue evolving at even faster speeds. Payers need digital solutions with the flexibility and agility necessary to respond to a health ecosystem that will continually demand adaptation.

5. Personalization and Ease-Of-Doing Business Tools

Demand for personalization is coming from all stakeholders. It’s not just consumers who want more control of health-related, data-driven decisions – payers, providers, employers and third-party health vendors are also looking for a hand on the steering wheel of quality, cost, and experience. Providing personalization and ease-of-doing-business tools to all stakeholders of health is a must-have in today’s market.

6. Interoperability 

Today, with mobile devices, social media, and more, individuals have access to a variety of real-time data right at their fingertips. On January 01, 2022, as a result of the Interoperability and Patient Access rule, this can include their health information. These rulings place tremendous pressure on payers whose legacy administrative solutions lack up-to-date security, data standardization and normalization capabilities, real-time data processing, and data interoperability with other payers, providers, and third-party vendors.

7. Access to Accurate, Real-Time Data 

Whether directly or indirectly impacted by the Interoperability and Patient Access Rule, new market demands to equip stakeholders with information that enables them to understand and orchestrate their health care needs and opportunities will challenge the entire health ecosystem. Payers will require administrative capabilities that can deliver exceptional data integrity, data insights, and data access – to their members and the stakeholders who contribute to their care.

8. AI-Infused Data Sharing

Data-infused member engagement and proactive outreach have the greatest potential to improve care, lower care costs, and increase member satisfaction. With artificial intelligence (AI)-infused administrative solutions, payers can move beyond “push” technology (requiring a user’s response) and “pull” technology (where users make requests) to engage with members. By architecting AI-driven data management and sharing capabilities, payers can leverage the information to alert and guide users through recommended health actions. Overall benefits will depend on the corresponding tools and technologies that AI can interact with and inform.

9. Digitally-Responsive Administrative Operations 

The silos of the healthcare industry are coming down and being replaced by a combination of individual and digital contributors who are free to orchestrate data-informed care in real-time. When enabled to function with greater independence, at faster speeds, and with more accuracy, the entire health ecosystem is experiencing a new state of boundless results. To stay in tune with this increasing tempo of ongoing digital disruption in healthcare, payers need to shift away from latent-legacy systems and towards digitally responsive, intelligent administrative operations.

10. A Trusted Technology Partner

Achieving administrative success will require a trusted technology partner who can help scope and build a future state and identify and remove the administrative tools and processes holding the business hostage. The partner should competently guide the transition to incorporating next-generation solutions that actualize data, improve care quality, increase user satisfaction, and lower operational costs. With self-serve capabilities, the health plan can readily adapt to new and changing regulations, care models, and any other unexpected changes.

Nearly 125 employees have participated in HealthEdge’s professional development program, now referred to as Emerging Leaders. Emerging Leaders is an experience designed for current and aspiring leaders to understand the personal and organizational behaviors required to be a strategic manager and leader within our organization.

Nominated by their managers, the program participants are strong cross-functional collaborators, strategic thinkers, and striving for a more significant manager or leadership role. When selecting the participants, we try to make sure the final group includes all functional areas and products to represent every part of HealthEdge in the program.

The program kicks off with a 360-review and a personality assessment called the Predictive Index, so participants can gain an understanding of where they are at, highlight their opportunities, and how they can get to where they would ideally like to be at the end of the year-long commitment.

In the first half of the year, the group meets once a month and participates in interactive training focused on topics including their own leadership styles, leading change, and communicating with impact. The trainings contain a mix of classroom sessions, interactive discussions, and group activities

Thanks to the feedback we received from past Emerging Leaders, we recently launched a formal mentorship aspect of the program. In the second half of the year, participants are paired with a leader to provide mentoring and direction as they drive towards their development goals. Mentors aren’t necessarily in the same functional area as the mentee. Matches are based on what skills the emerging leaders are looking to improve. Then, we find leaders at the company with strength in that area to help coach them and build on that area of focus.

Another benefit of emerging leaders is the ability to gain exposure with other leaders within the organization. We strive to create an open forum where participants can have open discussions, participate in breakout groups, and work with people they have never met before. There is a lot of collaboration, sharing experiences, and talking through approaching a similar situation or solving a common issue.

We strive to make sure the program is not generic for everyone but tailored to each person and helping them figure out where they need to grow and provide the tools to help them become effective leaders.

HealthEdge was recently named national Elite Winner in Employee Achievement and Recognition designation for the 2020 Medium-Size Best and Brightest Companies to Work For, Top 101 in the Nation®. We are also a proud winner of Boston’s 2020 Best & Brightest Companies to Work For® award, three years in a row, Boston Globe Top Places to Work, and Top Places to Work in the Nation in 2021.  Want to work with us? Check out our current job openings.

To remain competitive in today’s market, health plans must invest in critical areas such as member satisfaction, care coordination, and adding new lines of business. Still, many have limited resources and tight budgets. Transitioning manual processes—like processing claims, which can have a considerable cost impact for health plans—to electronic, can save plans and providers billions of dollars.

Headquartered in Brooklyn, New York, Elderplan is an established, not-for-profit health plan organization, serving 27,000 members and meeting the needs of Medicare, Medicaid, and Dual-Eligible individuals at every stage. For nearly 30 years, Elderplan has offered a wide range of innovative health plans.

In 2015, Elderplan’s Medicare auto adjudication rate was 47 percent, and the HomeFirst auto adjudication rate for Managed Long-Term Care was 77 percent.

More than half of the claims that came in were pending on the Medicare side, requiring significant time spent on manual adjudication of the claims and taking away from focusing on making continuous improvements and that attract and retain their members and drive success in their business.

Given these challenges, Elderplan needed to maximize operational efficiency, control administrative costs, and embrace evolving business models.

As Diane Pascot noted, “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.”

Prioritizing operational efficiency would result in critical savings and enable Elderplan to redeploy resources typically spent on routine administrative tasks and shift to transformative projects. The health plan knew it needed a core administration system that breaks down product design barriers, increases efficiency, and delivers real-time transparency.

Continue reading this case study to learn how next generation technology enabled Elderplan to cut costs and maximize efficiency, while providing the flexibility to respond to unforeseen circumstances such as the COVID-19 pandemic quickly.

I recently participated in an AHIP webinar, “Growth and Innovation with a Consumer-First Future,” with HealthEdge customer Sal Gentile, CEO and Co-Founder of Friday Health Plans, along with UST HealthProof’s CEO Kevin Adams and Healthproof President Raj Sundar.

During the webinar, we polled the audience of health plan employees about what metrics matter most. “Member and provider satisfaction scores” ranked at the top, even over financial metrics. This represents an evolving point of view for health plans, who are increasingly recognizing that “members” are customers and consumers of their services.

Health plans can measure how well they are doing in a number of different ways. Take a government program, for example. Success depends on keeping costs low, staying compliant, STAR ratings, etc. While all of those factors translate to financial health, they’re built upon customer satisfaction.

For Sal Gentile, customer satisfaction is a key requirement for keeping their business growing, “Member satisfaction fuels our growth because the renewal rate is critical to our success. We can’t count on always winning in a market and taking somebody else’s members; we have to count on starting with renewing our own members first. And so, if we don’t satisfy the customer, we won’t last.”

Kevin Adams weighed in about what is required for customer satisfaction, “Customers can be members, providers, brokers, whatever the constituent is. And being able to surface the information and the needed response in real-time, it is the fundamental piece that outlines success in providing a better customer experience.”

Health plans need modern technology that offers transparency and provides access to real-time data and information across the entire enterprise. A customer service team cannot have a desk covered in sticky notes with exceptions and different rules outside the system. They need up-to-date information at their fingertips.

“Customers are satisfied a health plan can solve their problem on the first call,” said Sal. “The tools and the plans we’ve put in place have allowed us to achieve a first call resolution of 99%. And when you can satisfy members and brokers and providers on the first call 99% of the time, you’re going to have a really good outcome when the renewal process comes along, and with word of mouth for adding new members.”

With increased importance on customer satisfaction, health plans realize that they are part of a larger ecosystem. They are not working in a silo by themselves anymore. Health plans with the tools that enable real-time data and offer transparency to the members and providers that are part of that healthcare ecosystem will achieve higher levels of customer satisfaction and ultimately growth and success.

When I came into the industry, we worked on green screen mainframes, where each function was its own application compartmentalized into silos. For an operations person, claims, eligibility, billing, and benefits were all in separate systems.

Eventually, organizations realized that the older technology was costly to maintain and began to move to the modern core system that encompasses multiple health plan operation functions in one application. The core system was less expensive and easier to use—no longer did someone need to exit one system and enter another system to gather information.

Over the years, the siloed approach comes up occasionally. Sometimes it may be an ambitious startup, companies that want to be disruptors in the market. However, it can also be large organizations as well. Regardless, this viewpoint of searching for a utopian IT state with each function to be a separate solution is something that persists and continues to cycle and come up from time to time.

Developing a claims system is not easy. It takes five to ten years of solid development and battle-proven, customer-tested processing (accumulating millions of transactions and scenarios over time) to get to a semi-mature state of a claims adjudication engine.

So, when an organization feels they can build a claims engine with individual components, i.e., eligibility, capitation, pricing, claims, benefits, etc., they tend to underestimate how complex it is and neglect to consider its impact on the end-user.

Logistically, plans need to consider all the integration an organization would need to create to connect and those separate systems. Often the integration effort turns into a ball of spaghetti code that becomes increasingly complex and costly to implement and maintain.

In my industry experience, the sought-after solution these organizations are a mirage and do not exist successfully. As it is not just the TCO associated with implementing and maintaining all the different systems; however, it is the end-user who suffers the most because they need to navigate across the separate applications in their daily course of work. Additionally, from an operations perspective, if a health plan wants to introduce one change—whether it is regulatory or market-driven—they must coordinate the change now across many systems, which is incredibly difficult and leaves a significant risk of error.

While data replication for members and providers becomes increasingly common today, based on my experience, I would argue that a core system’s minimum viable product (MVP) provides benefit configuration and claims adjudication in the same container.  Additional required pieces of adjudication can be replicated with comprehensive APIs for the core system provided as a standard by today’s measures.  The reconciliation of transactions between systems and remediation of fallout are the bigger pain points that usually need to be addressed.

Nonetheless, on top of the MVP by adding flagship pricing (Burgess Source) and care management (GudingCare) capabilities complementing HealthRules Payer’s open integration, business empowered automation, configuration, and provider capabilities shape the unified vision of the HealthEdge solution into a best-in-class approach that provides the maximum value to our customers.