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Stuart Myer, Chief Information Officer, VillageCare, a community-based, not-for-profit organization in New York, recently joined HealthEdge leaders Christine Davis, Vice President, Product Marketing and Len Rosignoli, Vice President, Customer Success in a live webinar to share how his health plan is advancing care management through digital transformation. The webinar was hosted by the Association for Community Affiliated Plans (ACAP).

In the discussion, Myer shared real-world scenarios that his organization experienced along its digital transformation journey and explained how every stakeholder in his organization is benefiting today. In case you missed the webinar, here is a snapshot of what the team covered.

1. Industry dynamics and challenges are driving health plan executives to realize that now is the time for digital transformation.

Workforce shortages, regulatory changes, evolving business models, and shifting consumer expectations are pushing health plan executives to seek new ways of reducing costs, improving efficiencies, and investing in innovation. Davis shared highlights from the company’s Annual Health Plan Market Survey that showed the majority of leaders are focused on aligning business and IT teams, as well as investing in innovation and moving to modern technology.

2. Digital payers are leading the way in transforming the industry.

“HealthEdge defines digital payers as those bringing business and IT areas together to create a modern, digital organization that constantly improves health and financial outcomes,” explained Davis. A digital payer can be identified by five key attributes:

1. Leveraging digital tools to improve end-user and member centricity.
2. Achieving higher levels of quality to deliver better outcomes for members and communities.
3. Increasing business transparency, breaking down siloes and improving exchange of information.
4. Advancing customer service by empowering teams with next-generation solutions.
5. Constantly reducing transaction costs through automation and connectivity.

3. VillageCare leaders implemented a digital transformation strategy that enabled a more data-driven approach to every aspect of their business, which is driving better care for their community and more efficient operations.

“Using a digital foundation has allowed us to become a data-driven organization that operates more efficiently. We are in it for better outcomes for the community we serve. A more efficient workforce delivers better care,” explained Myer.

Using the GuidingCare® platform from HealthEdge, VillageCare was able to support their top business and clinical objectives in many ways, including:

• Improving clinical and business operations through integrated work processes
• Creating a data-driven organizational culture
• Advancing clinical partnerships through data integration
• Sharing data with members and clinical partners using industry standards
• Using best-in-class applications that integrate to create a seamless systems environment

4. Becoming a digital payer transformed experiences for five key groups across VillageCare and the healthcare ecosystem in which they operate:

• Members: VillageCare consolidated data and streamlined process to better enable a member-centric approach. They migrated disconnected touchpoints (such as finding providers and eligibility, benefits, and cost information), to easy-to-use, self-service tools within GuidingCare. With a frictionless member experience, they increased member engagement and satisfaction, while ultimately improving health outcomes.
• Providers: The organization transformed their relationship with providers by delivering instant access to real-time patient benefits, claims data, authorizations, and more in GuidingCare’s easy-to-use digital collaboration tool.

“One way we were able to improve the experience for providers was the GuidingCare Utilization Management application that is tightly integrated with the claims processing system,” Myer explained “This process was a big pain point for our staff. Many health plans have staff managing these processes in separate environments, manually entering information into both systems. We solved this problem, and as a result were able to launch an authorization portal. So rather than having providers fax or make phone calls to request authorizations, they can now request them electronically. We also use a claims portal where they can check the claims outstanding.”

• Member Services: VillageCare streamlined the disconnected workflows that were a result of multiple software systems and improved access to information to transform the experience for their member services teams. With better tools and more accurate, real-time data, member services teams have been able to improve service quality, reduce costs, and improve the member experience.
• Care Managers: VillageCare also eliminated functional siloes and put accurate, up-to-date data in the hands of care managers to streamline workflows and improve outcomes.

“We aim for integrated, care management processes. Systems should support the work processes, which was not always the case. But through our digital transformation and using GuidingCare, we have much more structed work processes. This frees up our care managers to focus on care management, while also forcing compliance and regulatory adherence through the system. In addition, we now have proper segmentation of membership so that we can develop real-time alerts, improve population health, and direct efforts where needed as opposed to being the same across the whole organization,” explained Myer.

• Information Technology: VillageCare has consistently focused on aligning business and IT teams to successfully use technology to address priority needs and challenges across the organization. By transforming the IT foundation, they delivered on their goal of becoming a data-driven organization. Now, the organization uses business intelligence to improve operations and deliver better care for members. In addition, through implementing solutions that use interoperability standards such as Fast Healthcare Interoperability Resources (FHIR), they have advanced integrations that allow for more streamlined processes and seamless workflows.

“The transformation has truly changed the way our teams operate, improving the experience for members, providers, member services, care management, and IT. All of these components are part of our digital transformation strategy. It is important to touch each of them and ensure that they talk to each other,” stated Myer.

VillageCare is addressing top challenges facing many health plan leaders today through their digital transformation journey,. They are delivering benefits for key stakeholders across the healthcare delivery systems by improving connectivity, enabling access to accurate data, and streamlining workflows.

Ultimately, the digital transformation is enabling VillageCare to deliver better health outcomes for the community they serve.

Learn more by watching the webinar here.

Leveraging his experiences as the Chief Information Officer at VillageCare, Stuart Myer discusses successfully attaining executive board buy-in for long-term technology investments.

Issues Technology Partnerships Solve for Safety Net Health Plans

Safety Net health plans face a unique set of challenges in comparison with other payers. These include an acute focus on community health and social determinants of health, an increased demand for complex care and more fragmented workflows.

Safety net health plans have been addressing these challenges while also seeking regulatory compliance, adapting their business models to align with patient demand for improved consumer experiences, and dealing with workforce shortages and the rising cost of labor.

One of the most effective ways to manage costs while comprehensively tackling these issues is through technology investment. By working with IT vendors offering interoperability and the sharing of real-time data among stakeholders, health plans can maintain ownership of their data while:

• Gathering reliable and accurate community health and social determinants of health data
• Fostering business transparency with all stakeholders including patients
• Developing and sharing complex care plans with all stakeholders and manage claims
• Creating digital experiences for patients to interact with and understand their healthcare

In the long run, such technology partnerships are some of the most impactful investments for health plans that intersects both cost and quality of care.

Barriers to Technology Implementation

Executives are highly concerned with cost savings. In fact, according to a 2022 survey of executive health plan leadership, the most pressing issue this year is managing costs.

Thus, it’s no wonder that despite the considerable benefits, upfront technology investment stands as a potential impediment to implementation.

Considering this, how can professionals approach their executive boards as well as internal teams to get buy-in on this important investment?

Tips For Successfully Obtaining Buy-In For New Technology Partnerships

Gain Leadership & Board Buy-In

Executive leaders championing new technology investment is a key driver toward organizational engagement and widespread buy-in.

The arguments for technology partnerships should be so compelling that the partnerships are not just approved for IT to carry out, but that the executive board co-leads the initiatives with IT and other departments.

The c-suite is concerned with every aspect of business and therefore has a finite bandwidth for championing initiatives. How do you make a technology partnership stand out?

Your technology investment cannot be presented as an IT project only. It must drive business strategy and align with blue chip items for the year. For instance, health plans may have long term goals related to risk mitigation and regulatory compliance. By explaining in as much detail as possible how this technology investment will deliver ROI on those goals, you’re more likely to get buy-in. If you’re having difficulty quantifying ROI, vendors often will work with health plans to develop reliable forecasts.

Myer suggests establishing a strong link between technology investment and organizational priorities. This ensures the project gets the attention and resources necessary. Health plan leaders can review their K10 or other strategic documents. Use short and long-term goals to create KPIs for deployment.

Continued support by the executive board is needed. There should be annual updates on progress to the c-suite. This investment should also be included as a component in the annual budget.

Identify Opportunities to Introduce Technology Partners

It takes time and effort to find the right technology partners. Consider how each vendor could grow with your company and the customization available in their solutions. Carefully review RFPs and connect directly to vendors through video calls and meetings. Make sure your vendor understands the unique challenges and opportunities of your health plan. What can they do to help your health plan meet these challenges?

Make sure technology vendors are:

• Cloud-based
• Have automated updates
• Allow for your firm to own your own data
• Offer raw data downloads to easily integrate into your platforms

3 Steps To Maintain Internal Momentum for New Technology Partnerships

1. Plan Strategy & Digital Transformation Initiatives

Health plans cannot fully implement new software to their tech stacks right away. Instead, technologies need to be integrated in phases. Myer suggests creating a detailed plan for when each integration will be deployed.

Start with the integrations most important and easiest to implement. Work your way down to more time-consuming and less impactful deployments.

For VillageCare, Myer prioritized data strategy first, as it was one of the largest pain points for the organization. For any given report, whether clinical or business related, there were multiple sources of information and large variations between statistics. This led to immense costs for VillageCare, in both resources and time, to validate data and discern which source was the most accurate for a given metric.  By leveraging GuidingCare®, Myer was able to consolidate reports and make decisions based on more reliable data.

Myer also recommends deploying cloud-based solutions within the first few months of launch. This allows health plans to take a foundational approach and put data warehouse capabilities at the forefront of technology investments.

2. Establish Governance

When deploying a new technology, it is important to develop a structured and formalized process for IT investments at an organizational level. Part of this process should be ensuring there is strong governance overseeing the implementation project.

One of the most important factors in VillageCare’s success creating patient-facing data portals was Myer’s creation of a governing board of members. These members provide feedback on projects and influenced VillageCare initiatives.

With member feedback, VillageCare captures and documents key needs and challenges of their population before and while developing member tools. This provides assurance that their investments will be received well by patients and minimizes troubleshooting post-deployment.

In addition to member governance, having an internal technology implementation team led by various department stakeholders, ensures the alignment of the investment with strategic initiatives and the company’s budget process.

To create an internal business governance, leadership teams and executive boards must first buy into the project.

3. Define Time Frame

It’s important to be patient with technology deployments. Estimate 2-5 years with key milestones before a strong ROI and organization-wide buy-in is seen.

For example, at VillageCare, Myer is in his 3rd year deploying GuidingCare. The past few months data strategy has taken off and is now part of the overall culture of the organization.

“It stopped being an IT thing and became an organizational mission” says Myer, “It is now embedded in our employee handbook. We offer a minimum level of training for staff and optional higher levels of training regardless of job function.”

To learn more about organizational buy-in for technology initiatives and VillageCare, view HealthEdge’s ACAP webinar If you’d like to learn more about GuidingCare and its capabilities find out more here.

In 2022, HealthEdge once again commissioned an independent survey of health insurance executives to capture and monitor perspectives regarding current challenges and priorities. There were over 300 responses received – from Directors and above in a variety of types and sizes of health plans.

We’d like to focus on one of the reported Top Challenges Facing Health Plan Executives – operational efficiencies.  The challenge of operational efficiencies came in second place and jumped 33% from 2021 to 2022, from 31% to 41% of respondents. To satisfy your curiosity, ‘managing costs’ came in first place, and ‘member satisfaction’ third in the 2022 study. In 2021, operational efficiencies ranked sixth. Member satisfaction and managing costs tied for third in 2021 behind ‘competitive pressure’ and ‘IT/business alignment’ (fourth and fifth in 2022, respectively).

When we began discussing and evaluating this internally, the comment came up about the pent-up demand for care as some consumers stopped seeking care during the COVID years of 2020 and 2021. It’s a complex dynamic, as the varying impact on payers and providers differ and could also be positive or negative.  Capitated health plan members seeking less care might be good for the provider financially, albeit temporarily. The influx of care may also have a positive or negative impact for payors and providers.  The increase in unemployment caused an increase in uncompensated care – but also an increase in Medicaid membership. It is anything but simple and there are many factors to consider – type of health plan, type of patient, type of reimbursement, conditions, diagnoses, contracts, etc.

Managing costs and operational efficiencies go hand-in-hand, so it makes sense that they both increased significantly in the responses for top challenges.  With the “great resignation”, the need to become more efficient is at play in all types of organizations – and is directly related to operational efficiency.

We’d like to focus on three potential areas to consider related to operational efficiency – auto-adjudication and first pass rate, digital transformation and return on investment (ROI), and staffing.

Auto-adjudication and first pass rate

Most health plans continue to focus on improvements to auto adjudication rate, a key indicator for improving operational efficiency. The obvious benefit here is the assumption that fewer claims will be touched by a human. However, first pass rate is often overlooked or not measured, and is equally, if not more important. For those that are unclear on the difference – the auto-adjudication rate is most often measured by simply calculating the percentage of claims successfully processed without manual intervention. Without more complex calculations, what is sometimes overlooked are claims that had previously suspended – maybe even more than once – and are now processed a subsequent time successfully – then counted as having auto-adjudicated, skewing the results.  Some of those claims were actually touched by a human, sometimes more than once.  First pass rate calculates those claims that were never suspended and successfully processed the first time. However, both measures help with evaluating operational efficiency.

Digital transformation and return on investment (ROI)

The buzz words “digital transformation” have been top of mind for the last several years, and remain a priority for improving operational efficiency.  What IS digital transformation? Each organization must carefully define what this means internally, but in general, it is increasing and improving the efficient use of technology. There is a cost to increasing the use of technology. There is certainly a ROI to come, and it’s critical to not only anticipate the ROI, but to continue to measure it.  The measurement can help to justify future improvements to and investments in technology once ROI calculation and measurement becomes routine and is demonstrated. The simple fact is that money must be spent to eventually save money – just like how converting a home to solar power includes a significant initial investment that pays off over time.

Software vendors are being asked more than ever to justify the cost of technology and demonstrate (in advance) the ROI. In some cases, ROI and/or performance guarantees are being built into software licensing agreements. The software industry should be positioned to explain and develop the ability to measure and commit to stated ROI for purchasers of their technology solutions.

Staffing

Operational efficiency related to staffing also increased in importance as most organizations are now trying to do more with fewer resources. Health plans are trying to become more efficient through higher automation of manual processes where applicable – and somehow enabling a corresponding increase in human efficiency. The so-called great resignation has health plans understaffed and has increased the urgency of this shift. Some did not anticipate the increase in staff productivity while working remotely.  While this is not true 100% of the time and not for 100% of employees, it has been true more often than not. Interestingly, in many cases, working remotely improved work/life balance – and consequently improved productivity.  This turned out to be operationally efficient.

Recruitment and retention are more critical than ever. Alternate staffing methods have become important to defend against this phenomenon. This includes some tried and true options such as 9/80 or 4/40 work schedules, part-time and shift work, full- or part-time remote work, additional paid holidays and/or time off, and other common staffing solutions. In addition, internship programs are increasing, as is the untapped value of the intern.  While many internship programs were and remain focused on the summer, many programs are now year-round. Many colleges and universities offer cooperative education (or co-op) programs – where paid full- or part-time jobs are taken for credit during what would be the typical school term (or longer). Internships are being made available to others, including recent graduates or master’s program graduates.

While the need for operational efficiency may increase or decrease in any given year, it is a continual challenge that can be achieved in many ways. We hope we’ve offered just a glimpse into a few potential contributors.

Read the full report here: Annual Market Survey Reveals What 300+ Health Plan Leaders are Thinking

The ‘pay and chase’ model of reimbursement is prevalent in the health care industry. This means many health plans know and accept the fact that payments to providers are simply incorrect and will require remediation.

At HealthEdge, we’re asking lots of questions about this traditional model and challenging the status quo.

• What if health plans modeled contracts before or during negotiations with providers?
• What if health plans understood how contract terms would affect their claims before putting them in place?
• Could health plans streamline contract terms and ensure that reimbursement methods pay correctly and automatically?
• Could health plans remove manual processes and rework?

Getting to the root cause of conflict

The friction between providers and health plans is multi-faceted. Erroneous payments are simply accepted, allowing the pay and chase model to be normalized and standard. But consistent errors wear on both health plans and providers. Allowing a claim to be underpaid or overpaid by even a few cents, will become a substantial amount over time, increasing tension between health plans and providers.

The pay and chase model also takes time away from the individuals working to remediate the discrepancies. Rework requires time to be spent on the same tasks that could have been correct the first time. Overall, this leads to waste in the form of time and dollars.

What is contract modeling?

Contract modeling can be thought of as testing terms for reimbursement. This allows a health plan to gain valuable insights into impacts of the terms within contracts prior to applying them to production claims.

Contract modeling can build a comparison of ‘what if’ scenarios to help a health plan make important decisions when it comes to negotiating provider contracts.

The benefits of contract modeling: how it can resolve the abrasion between health plans & providers

Contract modeling can also be valuable to a health plan that is negotiating contract terms with a provider. It will allow for the health plan to understand the contract terms and their application to claims, while also bringing the same clarity to the providers, creating a strong and transparent relationship.

A comprehensive approach to accuracy & efficiency

Can we change the status quo of reimbursement with contract modeling? Perhaps the process of creating provider contracts is backwards. Instead of the traditional approach, what if we first know and understand the payment that providers are expecting and how contracted terms will behave on claims prior to negotiations? With a complete and transparent approach, we can stop the pay and chase model and start paying claims accurately and efficiently the first time.

We all get the emails – mid-year check-in, annual reviews. These performance reviews are designed to help us continuously grow and develop throughout our career. Your manager and/or mentor can provide you with the support to grow and evolve – but there’s only one person who owns your growth and how you invest in yourself.

Your personal development is your responsibility – and it comes with a host of benefits, including personal satisfaction, increased career opportunities, improved brain health, and the joy of continuous learning and mastering something new.

What does owning your growth mean?

Personal growth and development means developing a vivid vision of what you want your life and career to become and establishing goals and a plan to achieve that vision. And taking the personal responsibility and accountability to commit to achieving that vision.

An important component of owning your growth is feedback. Along your path, are you asking for feedback? A helpful 3-question framework is:

• What am I doing well?
• What do I need to do more of?
• What do I need to do less or stop altogether?

It’s so easy to get off-track on our quest for personal development. Work, family, digital distractions, information overload, the feelings of failure/not progressing fast enough are demons lurking in the wings – waiting to derail us from our personal growth. This is why it’s so important that the drive for personal development comes from you – it has to be internally driven to stick. Develop a vision of your life that’s so compelling you can’t help but be pulled toward it.

Why invest in your personal growth?

What happens if you don’t invest in your personal and professional growth? One of the biggest risks is stagnation. Another is if you’re given feedback and don’t do anything about it.

A growth mindset coupled with personal development can lead to increased creativity, opportunities at work, problem solving, and even improved brain health. According to neurosurgeon Dr. Sanjay Gupta, learning new skills is one of the best ways to keep your brain sharp.

How do you invest in your personal growth?

There are many ways to learn – YouTube, classes, webinars, coaches, books. The options are nearly endless – but the key is to select what you want to learn, how you’re going to learn, how you’re going to immediately apply it – and make a commitment to yourself to see it through.

For example, if we think about learning a second language. There are so many things to learn – how do you learn without feeling overwhelmed by the magnitude of the task. We follow this framework and break down a big goal into manageable chunks:

• Select what you want to learn: I’d like to learn Spanish and be proficient enough to have basic conversations.
• How I’m going to learn: I’m going to take a weekly class, learn vocabulary with notecards for 15 minutes a day, and do Duolingo every day.
• How I’m going to immediately apply it: I’m going to find a weekly Spanish meet up group, join it, and practice speaking.
• Commitment: I commit to taking full ownership of this goal. I am responsible and will see it through.

A couple important notes include:

• Make sure to give yourself permission to take the time. It can be so challenging with work, family, and life obligations to make the space for something that feels like an indulgence. But personal growth is not a treat – it’s vital to your life and career.
• Turning your goals into daily habits is a great way to see success at something new. The book Atomic Habits is a great read on effective habit building. Comedian Jerry Seinfeld uses a calendar technique to keep his daily habits on track.
• We don’t retain new information unless we apply it. Any time you learn something new you have to immediately apply it. The more you use your new knowledge the stronger those neural connections become.
• There’s no one size fits all when it comes to personal development and/or learning. This is why it’s so important for you to own your growth.

Owning your personal growth

The feeling of mastering something new after a concerted effort is sublime – a potent combination of pride, accomplishment, and gratification. Leaving your personal development to only what is mandated by your manager robs you of the opportunity to feel this joy.

Give yourself permission to invest in yourself. To your success!

Managing costs and improving operational efficiencies jump to the top of the list in 2022 Health Plan Market Survey

Every year, we conduct a survey of hundreds of health plan executives. This year, more than 300 health plan leaders responded, and the full research results can be found here.  One of the biggest changes that surfaced in this year’s results was the sharp increase in the number of executives who are concerned about rising administrative costs. This blog explores the research results and some of the drivers that are impacting costs – along with some practical advice on how some of the most successful plans are taking the challenge head on.

Results Reveal Heightened Attention on Managing Costs

As “managing costs” jumped from near the bottom of the list in 2021 to the top of the list in the 2022 Health Plan Market Report, the shift reflects the monumental changes that are going on in the market today. Everything from aging technology that is not able to keep pace with market changes to increasing regulatory pressures, administrative costs have been rising. Let’s break down the key factors driving the heightened focus this year.

1. Aging technology: As member expectations of their health plans evolve to be more in line with what the experiences they have with other parts of their lives (retail purchases online, personalized service, price transparency), payers are being forced to respond with higher service levels. The growing number of regulatory requirements are also putting pressure on aging systems to make available data to members and other stakeholders. New market entrants with more innovative approaches to benefit plans and services are threatening the market share of traditional payers, resulting in the need to be more agile and creative.

Aging systems directly impact administrative costs. For example, systems without flexibility to support new payment models requires more manual work or results in missed opportunities. Legacy systems that are incapable of seamlessly exchanging data with other systems require manual data entry that increase labor costs and introduce the risk of human error. Also, systems that can’t facilitate advanced automation increase the cost per claim by adding even more manual intervention. In fact, in this year’s survey, we saw the cost per claim increase for more health plans this year – with 58% of survey respondents reported their cost per claim is $8 or more, compared with 44% the previous year.

Outdated, legacy systems were never designed to be flexible and open. They were mainly designed to process claims. As payers seek to respond to the market demands, they are having to make tough decisions about whether to continue to invest in their aging systems and more manual resources or move to more modern, open systems.

2. Workforce dynamics: The labor shortage is also driving up administrative costs. With fewer staff members and rising wages required to attract and retain qualified resources, operating expenses are increasing. In addition, when the technology is not easily adaptable, health plans are forced to hire more people just to cover the basics, like maintain compliance with new regulations and meet member and provider expectations. As backlogs build up and service levels go down, so does the health plan’s ability to positively impact member outcomes. The impact of having fewer resources available in a business that is heavily depending on manual processes has far-reaching effects on virtually every component of the organization.

3. Regulatory Changes: More regulatory changes have occurred in the past two years than in the previous 10 years. All of this change typically requires modifications to the underlying systems that generate the data and run the workflows. Without a modern, flexible system, health plans have to use manual resources and add more work to their already overwhelmed IT departments, which in turn, impacts costs.

When asked what their top challenges were when it came to staying compliant with CMS’ frequent changes to quality standards and payment rules, the top two responses were:

1. Technology/infrastructure cannot keep up

2. Lack of IT staff or resources to make changes

3. Interoperability mandates

4. Post-Pandemic Care: During the pandemic, patients delayed care, creating gaps in care and sometimes costly complications. As those patients return to their physicians and hospitals for care, claims volumes have increased and so has the cost for the care. This surge in claims is putting further strain on inefficient and manual processes.

Digitization Can Drive Savings and Growth

To address these challenges, health plans are looking for ways to get more from less and finding investments in modern technology to be a smart solution. And when costs are reduced and efficiencies are gained, leaders are bullish on the future of the industry.

When asked what leaders would do with the savings captured from lowering costs and finding new operational efficiencies, the top three answers were:

1. Invest in new geographies or lines of business
2. Consider new partnerships or acquisitions
3. Reallocate for further innovation

HealthEdge currently provides best-in-class solutions delivered on powerful, digital transformation platform that enables more than 100 health plans tackle these tough challenges today. Modern systems from HealthEdge provide the true integration capabilities, advanced automation, and access to real-time data that is necessary to drive down costs. Replacing outdated, legacy systems with modern technology made to support the demands of today’s market not only opens the door to new operational efficiencies, but also enables greater opportunities to increase member satisfaction and drive new revenue opportunities.

For more information on how HealthEdge can help your organization manage rising administrative costs, visit www.healthedge.com or email [email protected].