Breaking Down Silos for Improved Member Experience

EHRs, mobile devices, wearables, claims data, and population health analytics can provide enough healthcare insight to improve outcomes at lower costs. But as the use of technology and data increases within healthcare, the challenge of effectively using that data also grows. The problem is that data exists in silos.

Recognizing this, payers are increasing their investment in innovation. According to our recent survey of 222 health plan executives, 50% said they plan to make significant investments in innovation to achieve their organizational goals this year—up from 19% in 2018. While there is a consistent pipeline of disruptive applications in the marketplace, few effectively connect the key constituencies, which the industry needs more than ever.

The McKinsey Global Institute estimates that the volume of healthcare data and the industry’s inability to take advantage of it, for whatever reason (HIPAA, old technology, business strategy, etc.), leads to potentially more than $300 billion annually in wasted value.

The first step to solving this challenge is better collaboration amongst payers and provider organizations. For payers and providers to align on shared goals, they must share critical data. Both administrative and clinical data can contribute to providers taking important proactive steps to get or keep their patients healthy.

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.

Furthermore, health plans that make accurate data directly available in real-time to their members and physicians within their networks benefit from greater efficiency. Customer service representatives spend more time efficiently resolving individual queries or speaking with more members on a daily basis, for example.

For members, it means they walk away from a shorter conversation with the right information or go in armed with the correct data to have a productive call – no frustrated call-backs necessary. The downstream impact of this? Increased member satisfaction—a top goal for health plan leaders— and greater likelihood of follow-through on care plans or better medication adherence to stay healthy.

Healthcare has a formidable challenge that persists: break down the silos between all key stakeholders. Only with technology that provides accurate data in real-time in a consumable manner by all will this occur. Of course, the players in the healthcare ecosystem have to want to collaborate and make the best use of these insights. Once that happens, better outcomes and an improved patient experience are inevitable.

How this Health Plan Cut Costs and Maximized Efficiency

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.

How Health Plans Capture New Business in a Competitive Landscape

Successful health plans are focused on expanding membership, increasing revenues, and controlling administrative costs. However, administration costs attributable to outdated technology and manual processes result in one of the highest sunken costs in healthcare.

Health plan operations, especially at smaller plans with limited resources, are pulled in a million directions. They are continually searching for ways to innovate and improve operational efficiency while reducing costs. However, as administrative expenses increase, tighter budgets become, and less money is available to reinvest in crucial differentiators and forward-thinking initiatives. Outdated technology and siloed systems can adversely impact operational efficiency, create significant processing challenges, drain productivity, and ultimately impact the bottom line.

For example, Michigan-based McLaren Health Plan’s outdated 30-year-old technology was resulting in a zero percent claims auto-adjudication rate. McLaren’s legacy solution was clunky, hard to configure, not user-friendly, and not scalable.

As Mike Comick described in a blog post, “At some point in time, the amount of road remaining for ‘investment modernization’ of existing organizational structure, use of data/business intelligence, and legacy technology is depleted. Ultimately the risk of minimal maintenance, or worse, doing nothing, is by far greater than ‘taking the big transformational jump.’”

McLaren agreed, as its Vice President of Business Information and Operations, Sara Mavredes, said, “We wouldn’t be in business if we didn’t make a change.”

McLaren decided that it needed to implement new technology that would allow the business to work more efficiently and intelligently, and that would provide it with the margin to implement new strategic initiatives like customer service, care coordination, new lines of business, and other innovations.

McLaren implemented next-generation technology and gained flexibility, transparency, and performance, critical for its success.

Continue reading this case study to learn how HealthRules Payer® enabled McLaren to respond to industry changes, reduce costs, increase efficiency, gain an edge over the competition, and more.

Value-Based Care Requires Payer-Provider Collaboration

Payers are increasingly incorporating social determinants of health (SDoH)— biology and genetics, individual behavior, social environment, physical environment, and access to health care and health insurance—into their members’ health predictions and working together with providers and community resources to fill these gaps in non-clinical care.

However, we still do not have a standardized way of collecting this data, which creates challenges. Furthermore, although it has been proven time and time again that aligning incentives between payers and providers improves care, some are still hesitant to fully collaborate. Thanks to the fee-for-service history, where providers depended on high-volumes, these two sides of the table can often be at odds.

When it comes to value-based care and SDoH, payers and providers benefit from breaking down silos, collaborating, and sharing information, but the industry continues to work in silos. To address these social factors and improve care, data must flow freely between payers, providers, members/patients, and community resources.

Sharing data and analytics can help with SDoH and understanding how it impacts high utilizing members. Bringing data systems together will improve payer-provider collaboration, enable better information exchange, improve quality of care, reduce costs, and provide much-needed transparency across the healthcare ecosystem to manage patient populations.

Health plans must have the tools and technology to collect the SDoH data, share the data, and develop and agree to Key Performance Indicators and take ownership of the scorecard that determines success. And, payers must leverage value-based models to encourage physicians to identify SDoH gaps and create goals or incentives around them.

Payers and providers who take a holistic, preventative approach to members’ care make an enormous difference in an individual’s health and well-being. To that end, SDoH are becoming as important as medical record information. While many payers are down the road with SDoH, the healthcare community in general still has much work to do. Continued partnerships with community organizations and other payers/providers will go a long way to address SDoH.

What Would a Do-Over Look Like For The Healthcare Industry?

Ever have the kind of day where you wish you could go back and start over? Press reset so you could avoid the errors you made the first time around? Unfortunately, that is impossible, yet thinking about it can provide some insights out how to move forward and make changes in the real world.

Take the healthcare industry, for example. What would a do-over look like if we had the opportunity to go back in time and make different choices? If one could wipe the current slate clean, how could we build a better, more productive, and efficient healthcare system?

Fee-for-service reimbursement is one stand-out do-over opportunity. People took each step thinking it was the right thing to do. Interventions designed to solve one problem layered on top of other interventions designed to solve other problems, without consideration on how they would impact the system as a whole.

Fee-for-service reimbursement models have resulted in several developments that merit a do-over:

  • “Sick-care” rather than Healthcare- The incentives associated with fee-for-service reimbursement caused our system to ignore people until they were “patients.” No symptoms, no illness, no service. The culture focused on treatment to the near exclusion of prevention.
  • Another artifact of fee-for-service, healthcare delivery fractured into specialized components between which there was little, if any, communication. Higher reimbursements for specialty services meant each patient engagement generated revenue. Each specialist treated their patient in a silo. The problem is that patients aren’t silos.
  • Treating disease, or proactively preventing it, is more of a science. The data proving benefit of treatment fidelity and lack of variation is there. For years, the concept of evidence-based medicine was eschewed by many providers.
  • The development and proliferation of IT systems that can’t communicate with each other.
  • The advent of an adversarial culture between providers and payers rather than one based on cooperation and collaboration.
  • The creation of a system that makes it all but impossible for consumers to identify and compare the cost and/or quality of services provided.
  • Zero incentive for providers to proactively engage with patients around chronic disease treatment and/or management.

Sometimes it seems going back in time is the only way to fix a problem that’s been generations in the making. On the bright side, the advent of outcomes-based reimbursement and value-based models has started to shift this dynamic. Collectively, we are moving towards an improved system based on quality, outcomes, and shared risks.

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.