Opportunities, Collaboration and Innovation in 2021

The biggest issue facing payers today is that their business changes every year. The pressure to develop reimbursement methodologies with providers that account for the quality of care, access to care, and value-based payment models has increased. Regulatory updates, the worldwide pandemic, and ever-present competition impact payers on an ongoing basis. There are also growing requirements for payers to transact with their members, providers, and employer groups in a modern way. Take Amazon and other B2C businesses; as consumers, we have become accustomed to an easy online buying process and have come to expect this with all transactions.

These collective stakeholder demands have resulted in an industry required to act, behave, and structure its activities in a completely new way. At HealthEdge, it’s our goal to get out ahead of that and help our customers meet, and exceed, these expectations.

We believe that health plans deserve to have a highly automated, accurate, real-time computing infrastructure, and we know our core HealthRules® product, while serving as the heartbeat of key payer operations, can’t do it alone. That is why in 2020, we acquired Burgess Source® to add claims payment accuracy, pricing, and editing, complementing and enhancing our existing adjudication capabilities and most recently Altruista GuidingCare®, the most successful modern care management platform in the marketplace. Our customers can come to work with us for the first time through any of the three products, as they are available on a standalone basis today and in the future and can work with any technology infrastructure in the market.

The integration of Burgess Source and GuidingCare with the HealthRules core administrative claims processing system allows our customers to experience significant benefits from the combined capabilities.

We’re bringing together best-in-class solutions that drive the three most important value streams within a health plan. These value streams cut across the administrative costs of running the business, the medical expenses of paying claims, and the effort to help members with acute or chronic conditions comply with their treatments and obtain better care and better lifestyles.

These integrated solutions make possible a vision where claims processing is enhanced with software-driven payment integrity at the point of service that feeds data to an end-to-end care management solution.

With three, next-generation, cloud-based applications, this combined solution suite is the first-of-its-kind. While each product is viable and extraordinary on its own, we believe the unique value is how these applications work together, enabling automation and workflow efficiencies in a meaningful way. Other options in the marketplace can take years to connect to one another. HealthEdge already has health plans across the country successfully using a combination of these products.

Together, HealthEdge, Burgess, and Altruista empower customers to effectively compete and be resilient to changes in the healthcare marketplace. We will continue to build out from our core system and enable our customers to add next-generation technologies that lower administrative and healthcare costs while improving patient outcomes and quality and supporting regulatory compliance.

As we embark on the new year, I am most excited to accelerate our levels of collaboration and innovation so we can continue elevating health insurance and healthcare.

Important Customer Update

HealthEdge’s Commitment to Customers 

The international COVID-19 outbreak has introduced unforeseen changes and uncertainty to all parts of our lives. During this time, HealthEdge wants you to know that we are here for you and committed to helping you continue running your business as you work with your providers and members.  We understand your business may be unusually impacted, for example by the increased need for healthcare services, putting additional strain on your resources. We are ready to assist you. Every day, customers rely on us to help them rapidly resolve real-time, business-critical challenges and COVID-19 does not change our ability to provide those critical capabilities.

Employee Focus

We take the health of the community and our employees seriously and are following the advice of medical experts and local authorities regarding steps we can take to help reduce the spread of the virus, such as social distancing. We have told our staff to work from home exclusively, and this policy will continue to be evaluated. We’ve also directed our employees to replace travel with virtual meetings during this time.

Agility and collaboration have been the focus at HealthEdge in our culture and how we approach our day to day support commitments.  Our staff are all deployed with equipment and toolsets that enable them to work effectively remotely.  Employees are trained in the use of video conferencing tools for virtual meetings to ensure our collaborative work focus for our customers continues.  Our internal support teams continue to support our customers 24x7x365, managing and monitoring any critical events that may occur.

We believe it’s our duty to play a role in reducing the spread of COVID-19, and precautions like these are in the best interest of our employees, their families, and the communities in which they live.

Crisis Management

The senior management team at HealthEdge is meeting daily to assess all aspects of the crisis and ensure that our resources are deployed to help you continue managing your business.  Please address any concerns to your Account Executive as we work through this unprecedented situation.

Payers and Consumers: The Path Ahead

Healthcare payers have a long history of thinking of themselves as fiduciary entities.  This self-image is changing by necessity, as consumers become increasingly savvy in evaluating and selecting the services impacting their lives.  Recent surveys, including one by Survata and commissioned by HealthEdge, show that consumers of all age groups want improved communication with their health insurer through multiple channels, particularly when it comes to understanding their benefits.  They also prioritize understanding their financial responsibility by “what do I owe?” both before and after encounters with providers.  Millennials, more than any other age cohort, want incentives for healthy behaviors from their health insurer. Health insurers who modernize their systems to effectively serve their customers will differentiate themselves as consumers increasingly make decisions influenced by online reviews and word of mouth versus brand loyalty.

Social Determinants of Health: Outcomes and Factors

Another area where health insurers can proactively influence health outcomes while lowering overall costs is in the consideration and proactive addressing of non-medical factors that impact their customers, known as social determinants of health (SDoH).  Factors such as isolation, access to transportation, healthy food, and stable housing have been proven to have a direct impact on the health of individuals and families.  Health insurers who partner with providers and community resources to screen for these factors and connect at-risk consumers to key resources have demonstrated they can bend the healthcare cost curve and improve lives in a tangible, measurable way.  Innovative programs funded and driven by health insurers such as UCare and Humana, for example, have resulted in healthier outcomes.  More attention to these factors involves high touch, on-the-ground outreach and strong community partnerships.  2020 will see some of these pilot programs become standard, while health insurers who have been watching from the sidelines will begin to act and get involved.

Cost Per Transaction

Along with thinking of consumers as customers, health insurers have an imperative to lower administrative costs, specifically for the myriad of transactions they manage internally.  Automating processes that have been handled manually, sharing information in real-time with customer service representatives, and providing information directly to customers electronically have been proven to lower costs and improve customer satisfaction.  In addition, resources saved can be reallocated to innovation, further enhancing health insurers’ competitive position.  Those organizations that focus on transforming to consumer-facing, hyper-responsive and digital enablement will be most successful in 2020.

Readiness for Change

Companies have formed new partnerships in many areas of healthcare, most notably in the health insurance market.  These entities, whether formed by established organizations coming together, the result of acquisitions and consolidation, or from new start-up endeavors, have disrupted more traditional models.  Each of these represents new forms of competition for the established health insurer, forcing organizations to act in response to new threats.  The path forward will feature new collaborations with providers, enhanced relationships with employers, and innovative offerings directly serving consumer needs.

No matter which path they choose, health insurers must have the flexibility to move quickly, while reconfiguring their products and businesses based on the changing dynamics around them.  The same applies to health insurers with government programs, as regulations are subject to change based on legislation, policy changes and/or legal disputes.  Health insurers who adapt rapidly with confidence and agility will emerge the winners.

Where does your organization fall on the change curve? How do you plan to adapt in 2020? Let me know.