Innovation at HealthEdge: Past and Future

The journey of transforming healthcare starts with innovation. At HealthEdge, customers can expect transformational business and IT solutions that drive superior business outcomes.

For more than 15 years, HealthEdge has helped customers of all sizes and lines of business transform their organizations, innovate, successfully compete, and achieve breakthrough results.

It all started at the inception of HealthEdge in 2005 with HealthRules Payer®. Our flagship core claims administration solution introduced the unique English-like HealthRules Language®, which transforms the benefit-plan design, network design and contracting process, and makes claims processing faster and easier, while delivering high auto-adjudication rates, high accuracy, and unprecedented transparency. HealthRules is a next-generation platform, recognized by Gartner, KLAS, and other reputable analyst groups.

In 2020, HealthEdge extended its offerings with the acquisition of Source to add claims payment accuracy, pricing, and editing capabilities to our existing offerings. With the acquisition of GuidingCare®, HealthEdge obtained the most successful modern care management platform in the marketplace. This year, we welcome Wellframe and its digital health management capabilities to the family.

Our growth and innovation timeline has led us to serve nearly 100 health plan customers with a combined solution suite that touches over 35 million covered lives across all lines of business. And we’re not stopping anytime soon. Together, HealthRules Payer, Source, GuidingCare, and Wellframe empower customers to effectively compete, improve healthcare quality, and be resilient to changes in the healthcare marketplace. The integrated ecosystem offered by these products moves customers closer to offering a full digital experience to their members.

Looking forward, HealthEdge is focused on three areas of innovation: efficiency in business processes and workflows; increased automation through analytics and machine learning; and creating an application partner ecosystem through API access and data exchange with the HealthEdge application platforms.

We are also committed to a digital-first experience for health plans that complements the composable future-state of the healthcare IT ecosystem. To keep up with digital disruption in the healthcare industry, payers need intelligent, next-generation solutions. Payers who do not invest in next-generation technology will likely be left behind.

As HealthEdge continues to grow, refine our solutions and integrations, and build out partner relationships, health plans can trust that HealthEdge will remain a leading innovation partner with a renewed focus on customer success. I am excited to see where 2022 and the coming years will take us.

Big Fail #5: Underestimating Long-Term Ownership

If a health plan takes the DIY path, what happens to its knowledge resources over time? In the “build” scenario, an organization owns the product and every challenge that comes with it. If something breaks or becomes obsolete, will the resources to keep it up be available? Will the organization be poised to chase innovation as its competitors are sure to do? Can the plan command the talent in the marketplace to keep its unicorn solution operating at peak value? When development talent and expertise erode, it will mean trouble. The expertise to train users and provide day-to-day technical support is critical to long-term success.

Management should prepare for an ongoing tide of integration requests. Contracting and partnership for these becomes a perpetual administrative function – another cost often overlooked.

As a health plan executive, ask yourself when considering the “buy or build” argument whether there is already a mature solution on the market that will do the job. In healthcare, smart vendors have already developed an interoperability infrastructure necessitated by recent government regulations. Look for this kind of commitment from any vendor in your own industry because it could make buying a solution even easier – it certainly does in the case of healthcare.

Executives should weigh what they hope to gain from building a proprietary solution when the hard work has already been done for them. Will this give them a competitive advantage? Do they have a realistic view of the risk and ROI? Can they invest sufficiently in the initial architecture to build a comprehensive solution?

We are a nation of do-it-yourselfers who take pride in self-sufficiency, but knowing when to tap the real experts is a strength, not a weakness. Remember the adage to “do only what you do best.”

Asking hard and far-reaching questions now will help you avoid Big Fail #5.

Portions of this blog post are excerpted from Ashish Kachru’s Forbes article “Why Execs Should Avoid The DIY Software Trap.” Ashish is President and General Manager of Altruista Health.

Big Fail #4: Trusting Newcomers Who Don’t Get It

In HealthEdge’s recent survey of 220 health plan executives, respondents cited increasing member satisfaction as their top strategic goal for 2021. When asked what steps they plan to take to achieve their goals, “improve engagement strategies” topped the list.

Laser-focused on customer service and outreach, payers are looking for new ways to enhance the member experience by leveraging digital technologies that enable improved communication, real-time data sharing, and personalized services, while increasing operational efficiencies.

Investing in digital health is on the rise. Rock Health reported, “It’s been quite a ride this past year watching digital health catapult from a niche sector to a mainstream market. The first half of 2021 closed with $14.7B invested across 372 US digital health deals with a $39.6M average deal size.”

The report added, “Even at its six-month mark, 2021 already surpassed 2020’s overall funding record.”

With the emergence of cloud-computing, API capabilities, artificial intelligence, virtual health, mobile apps, and more, the healthcare industry has seen a boom in digital technology startups with solutions aimed at improving care and lowering costs.

The digital disruption puts tremendous pressure on payers and providers to invest in next-generation technology or get left behind.

In this environment, health plan executives should be especially wary of vendors with “DIY” applications who are trying to enter their industry for the first time. Over-confident players with simplistic approaches underestimate the industry’s intricacies around lines of business, regulation, data, clinical practice, financial dynamics and consumer trends. Decision-makers should skip entities with a core focus elsewhere or who are spreading themselves across too many disparate businesses.

Vendors with success in other segments of the economy aren’t guaranteed the same outcomes elsewhere. No business should settle for being someone else’s experiment. That’s key to avoiding Big Fail #4.

Don’t miss the final installment of the 5 Big Fails of DIY Software. The last segment talks about the big-picture, long-term costs associated with your DIY platform.

Portions of this blog post are excerpted from Ashish Kachru’s Forbes article “Why Execs Should Avoid The DIY Software Trap.” Ashish is President and General Manager of Altruista Health.

IMPACT 2021: The Journey to Transforming Healthcare

Here at HealthEdge, we have a rich history of hosting highly interactive and engaging customer conferences. It’s always been one of my favorite things we do because it allows us to bring our HealthEdge community of customers and partners together to exchange ideas, share lessons learned and talk about where we see the future of healthcare going.

Due to the pandemic, this year we hosted a virtual customer conference, IMPACT 2021, and it was an amazing event. We welcomed nearly 200 customers, ranging from those who have been with us since our inception to those who recently joined the HealthEdge community through our acquisitions of Burgess and Altruista Health.

During the four-hour session, we shared our vision of leading the digital transformation of healthcare through best-in-class products and an integrated platform, and they shared with us their plans, challenges and hopes for the future.

The purpose of this article is to share with you some of the highlights from my keynote address and encourage customers and prospects to reach out to their account managers and engage with us. Together, we are transforming the business of healthcare. I invite you to join us on this incredible journey.

Our Community is Growing

As our customers expand into new markets with new lines of business, we too have expanded our scope of offerings. After finding the right capital partner, Blackstone, in 2020 to help support our ambitious growth plans, we were able to bring into the HealthEdge family two businesses, Burgess Group and Altruista Health.

These additions brought more than just powerful, best-in-class products in the areas of payment integrity and clinical care management. They brought incredible teams of talent, packed with innovative ideas and best practices from across the health plan industry.

Bringing these bright minds together to plot our course of how the solutions will work together to drive incremental value for our customers has been nothing short of amazing.

Since then, we’ve double the size of the company both in terms of revenue and employees.  Today, we work with 90 companies, including national and regional health plans, commercial and government plans, BlueCross BlueShield plans and specialty claims processing organizations. We cover more than 35 million lives and virtually every line of business.

Building a Bright Future: For our Customers, with Our Customers

Our mission is to empower our customers to drive higher levels of automation and efficiencies while also reaching higher levels of member and provider satisfaction… and ultimately achieving growth. We accomplish this by focusing on our five core principles:

  1. Optimizing business value for our customers and employees
  2. Facilitating cross-functional collaboration
  3. Driving continuous process improvement
  4. Following first-principles thinking
  5. Enabling engineering excellence on behalf of our customers.

In fact, everything we do is for our customers. We’ve built this company for our customers, and the collaborative culture we share with them has been the key to helping us all solve some of the biggest challenges facing healthcare today. And I believe if we continue to focus on these core principles, we are uniquely qualified to lead the transformation of healthcare together.

The Journey of Transforming Healthcare

As health plans expand into new markets and healthcare consumers demand more personalized services, the need for automation and transformation has never been greater. At HealthEdge, our overarching product strategy centers on two main themes: (1) deliver best-of-breed solutions across our customers’ businesses that can (2) easily integrate together accelerate time-to-value for our customers. Let’s take a closer look at what we mean by these two themes.

Deliver best-in-class, individually excellent solutions.

  • Offer the finest claim system that gives our customers flexibility and agility to run their business – that’s HealthRules® Payor. We’re expanding our capabilities to support things like value-based care, expanded benefits design, and advanced integrations.
  • Offer the best claims editing and pricing rules engines to facilitate more accurate claims and higher payment integrity – that’s Source®.  Our Burgess team does a phenomenal job of maintaining the most up-to-date payor rules and pricing engines.
  • Offer the best care management system that empowers clinical teams to provide optimum care in the most cost-effective manner – that’s GuidingCare®. Our Altruista team is obsessed with coming up with new ways for clinical teams to monitor the quality and utilization of care services to generate the best outcomes.

Deliver an integrated suite of solutions.

By having all three platforms under one roof and our solution teams working closely together, we can more quickly build seamless connections and workflows that can:

    • Share more data in real-time for better insights and informed decision making
    • Drive smarter business process that take the burden off administrators and clinical resources
    • Generate extreme efficiencies, better care and more satisfied members and providers.

A Look Ahead

With our wide range of customers, our solutions exist in a wide variety of ecosystems. But as we look ahead to our product strategy for the next few years, there are four common denominators that will guide our product investment decisions:

  1. The need for end-to-end automation. The manual-intensive business processes that exist across health plans and providers are placing undue cost burdens that threaten our ability to deliver quality care in the future. We’re rethinking every process and finding new ways to automate the business of healthcare.
  2. The demand for real-time data. Being able to make more informed administrative and clinical decisions is dependent on being able to access the right data at the right time. We will continue to expand access to all types of data through advancing our API framework.
  3. The move to expand into new markets. Helping our customers quickly and confidently move into new markets or grow their lines of business requires flexible solutions. We’re focused on increasing the configurability of our solutions so our customers can adapt faster to changing market conditions.
  4. The shift to value-based care. From setting up value-based arrangements to accurately pricing value-based claims, we’re focused on making it easier for our customers to compete and win in value-based and risk-sharing arrangements with greater access to the clinical and operational data they need.

Beyond the Highlights

Packing a 45-minute keynote address into one brief article is an impossible task. We have so many innovative things going on across our business and across our customer base. I hope that you will stay tuned for more posts in the coming weeks as I dig deeper into each component of our strategy and our product leaders lay out their respective roadmaps.

For now, please know that we are grateful for the level of energy and enthusiasm we receive from our customers every day, and we are encouraged by all of the innovative ways they are using our solutions to grow their organizations and make healthcare better for everyone. Thank you to every one of our customers, partners and team members who made IMPACT 2021 such as success.