Month: March 2022

The term composability has emerged as a popular topic among healthcare industry analysts and CIOs. But what does composability really mean and why should care management leaders care if they have composable systems sitting on composable architectures?

We thought it would be helpful to de-mystify the term and talk in real-world business scenarios that show composability in action so you can better understand what it means and why it is important.

But first, we’re going to look at a formal description of a composable architecture that was used in a recent article in Architecture and Governance magazine. The article reiterates Gartner Group’s definition of the building blocks of composable architecture to include business architecture, technologies, and thinking. As these are foundational to any organization, managing composability is somewhat easy as the pieces are already there.

The article goes on to say, “Composable architecture brings a new way of understanding how the existing pieces fit together, essentially expanding the way enterprise architectures use existing competencies. When shifting the approach toward composability, enterprise architects embed adaptability in design, and enable the enterprise to plan for many futures.”

What does composability mean for care management software?

Practically speaking, what does that mean? Perhaps the easiest way to understand composability is to examine its opposite: monolithic.

With many monolithic, legacy care management systems, the vendor requires an all-or-nothing approach to purchasing and implementing the system. In order to accomplish the tasks the system was designed to do, health plans must implement the entire system at once. This often leads to lengthy implementation cycles, heavy IT burdens, and frustrated business users. And the industry is changing so rapidly, the requirements of the system are likely changed many times over during the time it takes to get the system live.

As the IT burden grows, so does the length of the implementation cycle, the cost of the system, and the impact of the missed opportunities that come with industry changes. This approach also results in health plans being forced to choose between best-of-breed systems that give them superior functionality and lesser quality but faster-to-implement systems that were “good enough.”

With GuidingCare, we are bringing the best of both worlds together with our fresh approach to composable solutions.

The Lego Analogy

Perhaps the easiest way to understand composability is to think about Legos. Anyone can sit down, take different shapes and sizes of Legos, and build something. That’s because the underlying system used to connect the pieces are standard and separate from the shape of the individual parts. You can buy individual Lego pieces and build something of your own, or you can buy pre-packaged Lego sets and follow the instructions to build something very specific. That’s essentially the way composable software solutions work.

The Benefits of the Lego Approach

With composable solutions, health plans get to choose which pieces of functionality they want to purchase and implement…and do so on their own timeline. Technically speaking, composable solutions reach into a shared services layer that allow certain pieces of functionality to work independently. This not only makes these solutions easier and faster to implement, but also gives health plans the freedom to choose which solutions from which vendors are right for their individual lines of business at the right time.

Composable solutions also reduce the IT burden because the interfaces are standardized and published for multiple vendors to use. For example, GuidingCare delivers pre-packaged interfaces with several different vendors. When the underpinnings are standard, building connections between disparate systems is easy.

Software vendors also benefit from delivering composable solutions. They can build and deploy new capabilities faster than if they had to deploy them in the context of larger, monolithic systems. The testing cycles are shorter, which enables vendors to be more responsive to changing industry and customer demands and move their products to market faster. And finally, composable software solutions are easier for vendors to maintain and access for issue resolution.

Putting the Pieces Together

For all of the talk about composability, the health insurance industry is still in its infancy compared to other industries. In a recent analyst report, healthcare ranked last among 16 different industries in terms of embracing composable thinking, business architecture, and technology.

Why is that? Perhaps the pace at which the healthcare industry is changing has risen so dramatically in the past 10 years that the legacy systems in place simply could not keep up. Ever since the Affordable Care Act was passed and then again as value-based care payment models come into vogue, health plans have been struggling to adapt and reimagine the way care plans are built and deployed, the way claims are generated and paid, and even the way business decisions are made. Composable solutions gives health plans a path forward and the ability to be nimbler and more adaptable as these changes occur.

Composable solutions are becoming an important selection criterion for modern care management systems. To learn more about composable and interoperable solutions, check out our new white paper, Transforming Healthcare: The Role of Open and Flexible Care Management Systems.

Historically, health plans were forced to choose between care management systems that offered best-of-breed functionality but required heavy involvement from IT and those that were missing key capabilities but could work seamlessly within the context of the organization’s ecosystem of other systems with limited IT effort.

However, times have changed. Modern care management systems, like GuidingCare® from HealthEdge®, enable health plans to get the best of both worlds – best-of-breed functionality in a highly interoperable and composable platform.

It’s important to break down the definition of a modern care management system to better understand the bottom-line benefits health plans should expect. There are three must-haves for modern care management solutions.

1. The system must be able to access and share a variety of data across the IT ecosystem. Important clinical data can come from virtually anywhere these days – from a primary care provider’s EHR system to a member’s Apple watch. In addition, non-traditional data such as social determinants of health (SDOH) data are becoming increasingly available and can unlock valuable insights into the member’s ability to follow their care plan. Claims data can also be mined to proactively identify patients who may be at risk of disease or costly complications.Much of this data is unstructured and difficult for outdated care management systems to assemble and turn into actionable information. However, all of this data is critical to care managers who are charged with understanding their member’s health risks and supporting the execution of care plans that help to minimize those risks.
2. The system must be able to accommodate real-time data exchange. It’s one thing to be able to share data across systems and care settings, but it’s another thing to be able to share data in real-time. Legacy care management systems were not designed to accommodate modern data exchange standards and are putting organizations at risk of missing critical opportunities to impact member health in real-time and expand their member services.Modern care management systems, such as HealthEdge’s GuidingCare, have embraced API-based integrations that allow them to share data in real-time through RESTful APIs and JSON payloads. This not only empowers care managers to help members avoid adverse events, such as hospital readmissions and falls, but it also gives them instant access to important member benefits information so they can make more informed decisions at the right time.In addition, more timely data is typically more accurate data. By ensuring the most current and accurate data is readily available to care managers, providers, and members, organizations can build long-lasting, trusting relationships.
3. The system must be open and capable of working seamlessly with other software systems. Care management systems sit at the core of every payer’s ability to do what they were originally created to do – facilitate care for their members. But in today’s complex healthcare environment, no single system can do it all. Many organizations have up to 25 different systems in their ecosystem that must work together to optimize member health and wellness.When these solutions cannot work together to take advantage of the strengths of each system, costly manual processes and custom workarounds are required. This drags down an organization’s ability to respond to member demands and market changes. Therefore, the IT overhead becomes an overwhelming burden that further erodes margins and puts the member’s experiences at risk.

Learn more 

To learn more about what a modern care management system can do for your organization, check out our new white paper, Transforming Healthcare: The Role of Open and Flexible Care Management Systems.

Interoperability may be one of the most over-used words in healthcare. Everyone has their own definition of the term, and everyone says they do it. But when it comes to the role interoperability plays in care management, it’s important for health plans to understand the difference between a system that says they support interoperability and one that can prove it.

The Definition of Interoperability

The most basic definition of interoperability was recently updated by HIMSS, and it reads, “Interoperability is the ability of different information systems, devices and applications (systems) to access, exchange, integrate, and cooperatively use data in a coordinated manner, within and across organizational, regional, and national boundaries, to provide timely and seamless portability of information and optimize the health of individuals and populations globally.”

But what does it really mean to your organization and how can an interoperable care management platform help you better meet the care needs of your members and the cost effectiveness of your care plans?

Well, it all comes down to being able to access and use important clinical and care plan data across your enterprise, including third-party systems that support your core care management system.

When done right, true care management interoperability means care managers can get access to up-to-the-minute claims data, clinical guidelines, benefit information, and more to help them have more focused conversations with members and construct care plans that can address an individual member’s healthcare needs more directly. It also means claims administration and payment processing teams can access real-time clinical data, which helps them improve the accuracy of the claim, develop more effective benefit packages, and enable better relationships with providers and members.

The Benefits of an Interoperable Care Management System

For health plans using modern systems, like GuidingCare®, the benefits of being able to seamlessly exchange information can be substantial, including:

• Access to more actionable data that can give better insights for smarter business decisions about member populations, market expansion, and cost containment.
• Freedom from having to use one care management system to do everything because the data is locked inside that one system. Data is free to flow between applications, vendors, lines of business, functional areas of the business, and even care settings.
• Care managers can make more informed decisions about their member populations, which results in better patient outcomes and lower utilization management costs.

How do you Know if Your Care System is Truly Interoperable?

It’s not just what vendors say, it’s all about what they are doing today. If you have a highly interoperable care management system, the following real-world scenarios are highly possible. These are scenarios that current GuidingCare customers have reported to HealthEdge:

• Claims data from multiple core administration systems inform care managers when putting together the proper care plan for a member in GuidingCare. Indicators such as repeat provider visits, lack of medication adherence, and missed encounters can be seen directly in the care management interface, enabling care managers to easily create the most effective care plans.
• Care managers get a 360-degree view of members enabled by HealthRules® Payor and GuidingCare working together to capture and present a more complete view of the member’s most recent history. This eliminates what would otherwise be the manual process of searching through claims data to piece together the pertinent longitudinal view of the patient’s history.
• Nurses eliminate manual data entry in GuidingCare because member-specific information automatically populates the system data and insights, such as prior authorizations, from HealthRules Payor.

Interoperability is important across virtually all systems that health plans depend on, but it is particularly important in care management since there are literally hundreds of applications health plans can use to optimize member outcomes and reduce costs. That’s why GuidingCare takes a multi-faceted approach to interoperability that includes an integration and API Suite as well as productized integrations with other vendors in its broad partner ecosystem.

To learn more about GuidingCare’s interoperability strategy, download our recent white paper, Transforming Healthcare: The Role of Open and Flexible Care Management Systems.

The one with the best data typically wins, right? We’ve seen it happen time and time again in our personal lives and in other industries.

If you are a parent of a teenager, you know that the data you’ve collected over the years of being an adult typically makes you a more informed decision maker than your teenager.

And just think about the amount of personal data Facebook has on its users or the amount of professional data LinkedIn can access about its users. The more data these social media platforms have about you, the more successful their advertisers will be, which ultimately results in more ad dollars being spent on the most effective platforms. The greater the data, the greater the success.

This same concept holds true in the healthcare industry. Those who are able to embrace the massive amount of healthcare data being generated by the digitization of healthcare are the ones who are most likely to succeed. Health plans that can use their data to automate more businesses processes, build better experiences for providers and members, and make smarter business decisions are the ones with the competitive advantage.

Data is Everywhere

All different types of healthcare data are funneled into payers from everywhere and at all different intervals. This includes everything from a member’s Apple watch to remote patient monitoring devices, claims administration systems, and even unstructured provider clinical notes. But how can health plans leverage this data to create competitive advantages and thrive in the new age of digital healthcare?

The secret is in the IT systems they choose. Building a solid foundation of workflows and business processes based on accurate, timely, and complete data that is centralized and managed efficiently is at the core of successful health plans. Let’s take a look at what good data can do.

For example, with a modern claims payment processing system like Source, health plans can:

• Adjudicate more claims correctly on the first try: By leveraging claims edit data to identify and resolve issues earlier in the adjudication process, fewer claims require rework and more claims get processed correctly on the first pass. This translates into lower transaction costs and higher margins.
• Automate more of the claims payment processes with new workflows, such as prior authorizations, because they trust that the data is accurate and is going to drive smarter processes that require fewer manual touches. This translates to lower risk of human error and helps reduce the burdens brought on by workforce shortages.
• Enable a better provider and member experience. When fewer over-/under-payments are made due to more accurate data, providers begin to trust these payers and can work more collaboratively to facilitate a better member experience. This translates to stronger provider relationships and higher member loyalty.
• Make better business decisions. With accurate and complete data, health plan administrators are in a better position to make more informed decisions. Modern systems, like Source, offer analytics and modeling capabilities that make what-if scenarios possible. Whether it is contract negotiations or adapting to new value-based care payment models, good data makes the difference between well-informed decisions vs. shots in the dark. This translates into better decisions that facilitate smart growth.

Accurate, timely, and comprehensive data can not only help you lower operating costs, but it can also give you insights that can be used to create distance between you and your competitors. And in today’s highly dynamic, rapidly evolving health insurance market, that distance is a welcome sight for many health plans.

Better data

To learn more about how to use your data to create a competitive advantage, check out our latest white paper and see 314 Billion Reasons Why Better Data Wins.

Health plans are constantly looking for new ways to reduce operational costs and improve efficiencies, but many of the issues that have plagued health plans for decades come down to one thing: the inability to get accurate, dependable, and transparent data.

Why is that? When it comes to healthcare data – it is everywhere, and it comes in many different forms, such as claims data, clinical content, edits, pricers, contracts, audits, and more unstructured data. Medicare is constantly evolving its policies, but the pace of change has dramatically increased in the past few years as government programs move toward value-based care payment models. Each managed care organization running state Medicaid programs has its own set of rules, waiver programs, and special pricing, as states attempt to meet the needs of their most vulnerable populations and the demands of the growing number of lives it must cover. And every entity updates its data set, pricing, and regulations at different intervals.

To further compound the problem, many health plans remain tethered to their legacy systems with no centralized way to make sense of the multitude of different data sources and formats; the human resources required to keep track of all these moving parts drag at profitability and stifles innovation.

To remain competitive, health plans need a modernized, comprehensive solution that can easily integrate with their entire ecosystem to orchestrate accurate data into every process and decision.

Now more than ever, payers need to make data accuracy a top priority. The trickle-down effect can be huge. Let’s take a look at the true cost of bad data:

1. Extreme inefficiencies: Inaccuracies due to disjointed data processes result in time wasted on rework and over-/under-payment recovery efforts. The cost to support these efforts is substantial.

2. Inability to adapt: More than ever, the continuously evolving healthcare landscape requires agile health plans. Lack of data transparency slows down health plans and prevents rapid responses to market conditions, like rising consumer expectations, ongoing legislative fluctuations, and new competitive entrants.

3. Provider burnout: A health plan’s legacy technology environment leads to poor processes, inaccuracies, and lack of transparency for providers to see and understand contracts. These gaps lead to administrative hardships and contribute to provider burnout.

4. Uniformed business decisions: Without complete data transparency, health plans may not fully understand the fiscal impact of an industry shift, such as a new CMS policy. This can lead to ill-informed decisions or even the inability to make decisions about reimbursement rates.

What Happens When We Get It Right?

While some vendor solutions claim to address these fundamental issues, their solutions are built on a legacy foundation, often designed for on-premise installations with additional, gap-filling solutions bolted on over the years through mergers and acquisitions. This perpetuates the current state of multiple instances with multiple update cycles and multiple data calls to claims systems.

However, some leading health plans are beginning to understand the value of addressing the root cause of data issues and favoring solutions designed to enable them to use their data as a strategic asset.

These solutions are designed specifically to empower payers by delivering:

• Cloud-supported infrastructure and single API
• Single update cycle
• Single call and single source for fee schedules and payment policies
• Single instance to connect with all claims systems
• Ability to automatically connect with third-party content within the same UI

Source is one such solution that challenges the status quo, giving payers more control over their payment integrity operations and greater transparency into their own data to orchestrate business decisions in ways that make sense to their unique challenges and operations.

If you are interested in learning how Source can help your organization reduce operational costs and improve efficiencies through better data, visit us at www.healthedge.com or email [email protected].

Better Data 

Check out our latest white paper and see 314 Billion Reasons Why Better Data Wins.

Background

Many health plan customers have historical workflows that rely on batch processes – file a claim on Day 1 and the results are available on Day 2 (or 3 or 4). Because of limitations with compute, storage, and network performance years ago, the idea of processing a piece of information in milliseconds was unheard of, primarily since it was not technically feasible to do it in a cost-efficient manner. However, in 2022, real-time, scalable, and global systems are commonplace.

Innovative companies across industries have taken advantage of these disruptive trends to deliver seamless, digital experiences that we take for granted today -– when we buy with 1-Click on Amazon or watch our Uber driver inch his or her way along the map on the way to pick us up. These become the baseline expectation. If you are the consumer of health insurance, you also expect to participate in these experiences. If you are the provider of that health insurance, you are expected to deliver this experience.

Real Time APIs (for Business Outcomes)

HealthRules Payor (and all HealthEdge products) are designed with real-time APIs. It is one of the reasons why Payor continues to be a Gartner Next-Gen solution for the Core Admin Processing Systems market. This is now table stakes for participating in this market and the baseline of our customers, who are modernizing for the coming decade.

Real-time APIs are the product that close the gap between various cloud-based health systems (CAPS, EHR, Pop Health, Portals, Mobile) and enable new experiences for members, providers, and users of these systems. Today, customers leverage the rich suite of real-time APIs to power member portals, send out correspondence, or determine member costs before they go to the hospital for a procedure. For example, HealthRules Payor real-time Trial Claim API allows for health plans to meet the government mandate for member specific pricing and cost sharing through the price comparison tools, as well as the AEOBs (Advanced Explanation of Benefits)

Real Time Events (for Business Outcomes)

The next stage of evolution for HealthRules Payor’s (HRP) integration capabilities is real-time event streaming, which is sometimes called stream processing. It sounds technical – but is conceptually easy to understand – and it solves some of the challenges that current businesses require to be even more responsive to customers. Created by LinkedIn over a decade ago and managed, now, as open source by Apache, Kafka is a technology used by most Fortune 100 companies to help with business events that occur thousands, millions, or billions of times per day (e.g., data from IoT (Internet of Things) device, a new member enrollment, LinkedIn message posts).

To achieve this, Kafka uses what is called a publish-subscribe messaging architecture. At the core of Kafka (and event streaming in general) is the concept of an “event” – i.e., something happened. It could be that a member got enrolled, a claim has been paid, or a heartbeat on a heart rate monitor exceeded a threshold. These events in small quantities or millions are “published” by applications (also called “producers”) and are “subscribed” to by downstream applications that need this information (also called “consumers”). And these events can be organized into logical “topics”. So, events related to enrollment go in one stream and events related to billing, perhaps, another. If each published event were a 3×5 card with information, those events are placed on to one of many user-defined conveyor belts in time order with each conveyor belt reflecting that different topic.

As a concrete example, an event could be a new member has enrolled for health coverage. As the source application, HRP “publishes” this event to the “Membership” topic. Any downstream application such as a correspondence solution for member ID cards or a member portal can “subscribe” to this topic. A depiction of this architecture is given below. If you want the fun, non-technical, children’s storybook illustration of how this works, please check this link out. It’s very well done.

Source: https://www.slideshare.net/KaiWaehner/the-rise-of-event-streaming-why-apache-kafka-changes-everything

HealthEdge’s objective with creating a Kafka-based event streaming architecture is to help our customers achieve digital transformation by democratizing the data in the HealthRules ecosystem, allowing them to leverage the power of “real-time” healthcare data to build modern, digital, world class experiences for their members.

Unique Capabilities and Use Cases

Because health plans are an ecosystem of integrated solutions with a CAPS at the core, there are some distinct advantages of this real-time messaging system that are especially relevant for payers:

Fault Tolerance – Because event producers and consumers are effectively de-coupled through this event streaming service, HRP can continue to publish events even if consumers are not online and vice versa. The events are backed up and consumed when the consumers come back online.

Performance – Kafka is extremely low latency (fast) and scales (powerful) to support millions or billions of events without impacting the core performance of HRP. Customers can continue to add events and topics with any number of consumers downstream and not impact HRP’s performance.

Highly Configurable – Instead of each additional use case for real-time data from HRP (and other HealthEdge products) needing an integration project or custom APIs, customers can use (and re-use) the same topics and published events across various consumers and configure these streams through a web UI.

Healthcare payors can configure and consume different data streams for a wide variety of use cases … use cases that we’re familiar and newer ones afforded by the performance and reliability:

Connecting with enterprise apps or other internal systems – Payors can use these data streams to connect to customer/provider service apps (enabling real-time response to customer and provider issues) or CRM (Customer Relationship Management) systems like Salesforce or to power new-age apps like chatbots.

Power their own AI/ML algorithms – The scale and reliability of these data streams enable payors to use them to power their custom ML models for complex use cases like fraud detection.

Analytics or dashboards – Customers with their own centralized analytics and dashboard capabilities can use the data streaming through topics to power these dashboards in real-time with claims, member and other HRP data.

A Step Ahead

Real-time experiences for members and providers are both here today, but also growing in sophistication and complexity to push the art-of-the-possible. HealthEdge is committed to keeping our customers a step ahead in delivering these experiences through evolving technologies applied to business outcomes.

Learn more about HealthRules Payor here.