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Bad data is estimated to cost the healthcare industry $314 billion annually and negatively impact an organization’s revenue by 10-25%. The claims payment structure is characterized by decentralized data and delayed pricing updates leaving plans scrambling to keep up with CMS and Medicaid policy changes and struggling to price Medicaid claims accurately.

Addressing this outsized demand on insurers and their technology partners requires getting control of your data. With annual stats like an expected Medicaid enrollment growth of 5.8% and a 9.5% claims payment error rate, technology that can make data more meaningful and actionable is the solution. Successful organizations have focused on three technology solutions to achieve consistent, accurate, and transparent payments:

• SaaS technologies
• Integrated ecosystems
• Centralized data

1. SaaS technologies

Challenge: Your traditional solution for first-pass accurate claims processing relies heavily on manual and infrequent data, and policy updates that are not aligned. Variability in pricing methodologies adds complexities to processing your claims.

Solution: A platform that delivers frequent updates to Medicaid baseline data with software as a service, so you’re always working with up-to-date prices and edits, preventing inaccuracies with real-time data. Because it’s in the cloud, no internal resources are required to deploy the changes. First-pass claims payment accuracy is increased dramatically – enabling your business teams to refocus on value-added activities.

2. Integrated ecosystems

Challenge: Multiple and different technology platforms across the organization impact the integrity of your data and the information exchange environment.

Solution: A unified platform that brings software, data, and service into a single workflow. Implementing one technology platform that delivers up-to-date regulatory data, claims pricing and editing, and real-time analytics tools gives your organization an edge over the competition. A single source of truth and a single point of accountability is a transformational approach for payers to make payments with total confidence and make business decisions with real intelligence.

3. Centralized data

Challenge: Your workflows and data are managed across multiple platforms that are not exchanging information in the same language, frequency, or format – wasting time and increasing the risk of errors.

Solution: A unified, cloud-hosted platform enables a single place to centrally update, maintain, and manage data with multiple entities. This automated approach reduces IT maintenance delays and delivers centralized, accurate data.

Source is HealthEdge’s prospective payment integrity solution, a cloud-based platform built to specifically address the burden of these challenges. Join our webinar on May 5 and learn how SummaCare modernized its processing and realized big savings. Register here.

Value-based care aims to improve the quality and outcome for patients by linking provider reimbursement to the quality of care provided. Under this system, providers are rewarded for helping patients achieve higher quality outcomes and thus lead healthier lives while reducing medical costs. Therefore, everyone benefits from value-based care.

However, when we talk about value-based care systems in the healthcare payer industry, there isn’t just one dimension to consider – there are many. It can mean disease management or compliance programs. It can mean programs that incentivize members with diabetes or heart conditions with waived office visit copays or gift cards. It can mean value-based reimbursement where providers are scored on analytics and capitated or paid on fee for services at higher versus lower rates depending on quality of care delivered.  Or it could be value-based referrals, where health plans refer patients based on the provider’s quality of care delivered.  The point is, value-based care can mean different things depending on who you’re talking to, what area of the industry they work in, the role they play, and the part of the health plan they represent.

These are the value-based care trends we’re seeing in 2022: 

1. Value-Based Referral Programs: How is this provider performing?

As part of the Value Based care model being created, Humana has added the analytical aspect to track performance of the provider quality of care being delivered. Higher quality of care showing reduced recurring costs identifies these providers as high quality.  Which translates to more referrals for higher quality providers and lower performance means less referrals over time until quality is improved.

This underscores the importance of analytics and advanced analytics enabled by artificial intelligence. Concepts such as data clustering or data labeling enables the business to define the criteria for these providers and the patients’ health overall based on claims volumes, costs, diagnosis, etc. The population can be looked at retrospectively and using predictive analytics trend the future for the health plan to help steer the ship of the enterprise. The result is the health plan is now empowered with the transparency to understand who their top performing providers and members are and to decide how to incentivize those constituents.

2. Provider payment & value-based care: capitation arrangements versus fee-for-service 

Provider performance is also being linked to capitation arrangements. Instead of having a fee-for-service approach, it’s taking the capitation arrangement approach and paying different capitation rates based on the quality of care that’s being delivered. One of the key business problems for a majority of the provider community is increasing revenue over time. In traditional for-fee-service arrangements, providers are paid per visit. They can see more patients and make more money based on volume, but that’s the complete opposite of the goal of value-based care and the adverse effect resulting in over utilization. The true goal of value-based care is increasing healthier populations through the quality of care delivered – which for health plans means a healthier risk-pool overall which translates directly to reduced PMPM costs.

COVID also raised a real challenge to providers that were predominantly working on fee-for-service arrangements. Initially patients had been avoiding the doctor for minor ailments, annual visits, or preventive care during the pandemic for fear of contracting COVID. In 2021, the AMA noted significant decreases in specialist spending noting drops of the hardest hit Physical Therapy (-28%) among others.  As a result, providers working on the fee-for-service type of reimbursement – where volume equals payment – have been struggling with the lack of patients. Capitated arrangements therefore really helped some physicians from having to close doors to their practices which has a direct impact on the patients that rely on them for care.

3. Medicaid & Value-Based Reimbursement 

If we think of value-based reimbursement from a fee-for-service perspective, that’s also something that we’ve seen in Medicaid for example. Where providers are being reimbursed at a higher level versus a lower level based on the quality of care that’s being delivered.  Being scored by the state based on performance, sending that score to the health plan administering that contract and paying at higher reimbursement rates for better performance is just another example or dimension of how we are seeing value-based care in the industry and provider payment practices.

HealthEdge: Enabling Value-Based Care

With all these different dimensions and players in the game. How does HealthEdge, or any software solution, enable value-based care for their customer?

1. Defining Quality of care: Quality of care is paramount and how it is enabled is a driving factor in value-based care. Disease management, compliance, quality of care referrals, and capitation rates all hinge on real-time, accurate data. Additionally, that data is used in the process of defining the quality of care metrics needed to identify top versus lower performing provider and member constituents.

2. Accurate, real-time data: Data becomes imperative to drive all of this. Data is the means to identify the metrics that health plans use to define their entire business landscape. In this case, a top performing or low performing provider is one small but powerful example. HealthRules® Payor enables our customers through the real-time data warehouse to critical insights that can be gained for membership, providers, billing, claims, benefits, contracts and much more. Empowering the business user to define their landscape as it relates to the specific dimension that relates to their role in health plan operations or the enterprise at large.

3. Benefits, Pricing, Capitation, Health Incentives: HealthRules Payor supports these areas from the core system in a variety of manners, mostly stemming from configurability. The HealthRules Language configurability is unmatched in the industry and automates benefits, pricing, and capitation in order to reduce customization costs that customers incur to meet their business demands. One of the many aspects of the HealthRules Language is it allows the business user to directly interact with their own user-defined terms in addition to 100+ first class system fields to create benefit and pricing rules that drive claims payments without the need to proliferate benefit plans. Additionally, User Defined Terms drive Premium Billing and Capitation rates providing the key to user empowered automation. That configurability and the automation that’s produced out of that is enabling our customers to develop these evolving pricing, benefit payment, and compliance program/health incentive models without creating custom code or requiring heavy IT support. We enable our customers through configurability of the system.

4. Health Incentive Programs: HealthRules Payor also provides Compliance Programs to automate the results of the benefit or pricing based on the members status in the compliance program.  The business is enabled to configure the applicable compliance for health issues like Asthma, Diabetes, Heart Disease, Smoking Cessation, Weight Loss, or Wellness as examples of what could be needed.  The nice features layered around the configuration is the ability to set automated reprocessing of claims based on retroactive changes in the compliance status of the member and automatically identify the claims impacts associated with these changes and provide the claims examiners the ability to review the financial impacts prior to impacting payments and approve or reject these adjustments based on their business processes.

HealthEdge MVP Value-based Care Ecosystem 

HealthEdge is enabling our customers through a best-in-class, MVP ecosystem for value-based care. Our accurate, real-time data warehouse powers determining compliance, provider quality level, reimbursement level, capitation versus fee-for-service, and more.

Our best-in-class products, HealthRules Payor, GuidingCare, Source, and Wellframe solutions enable our customers to achieve better outcomes that are critical for value-based care.

Contact us to learn more about HealthEdge and value-based care.

Mental health is receiving more attention across healthcare and as President Biden unveils broad changes in his budget bill released in March. Many see the pandemic as both a crisis and an opportunity to strengthen the nation’s mental health system.

Some strategies under consideration include payers being required to offer three behavioral health sessions at no charge to patients in private health plans. Another shift would be to apply the 2008 Mental Health Parity and Addiction Equity Act to Medicare. Recent administration moves seek larger networks of behavioral health providers built into benefit plan design and training for the mental health workforce.

Parity is a hot topic in Congress. Payers are required to cover mental health to the same extent they cover physical health under the Parity Act. However, three federal agencies recently reported to Congress that 30 health plans and issuers were out of compliance with the law.

Provider shortages contribute to this picture, with mental health professionals remaining out of network at a rate of five times higher than other provider types. Consumers are often discouraged by delays in getting first appointments or in facing out-of-network fees. Payers say they need more guidance on mental health parity rules and clarity on how to document compliance to the satisfaction of regulatory agencies.

The Senate Finance Committee may be the driver of change as members of both parties search for ways to strengthen access to care, especially post-pandemic. Levers for change could come through the modification of Medicare and Medicaid policies. Other momentum could come from pandemic advances in the use of telehealth and a trend to integrating primary care with behavioral healthcare. While there are issues in prescribing medications to parse, most parties agree that the telehealth flexibilities of the pandemic should be extended. Legislation may come as early as this summer, potentially creating a bipartisan win. Previous mental health parity bills have largely been supported by both parties.

Mental healthcare may be having its moment as the nation appears to unwind from the prolonged pandemic. Experts have expressed concern about the nation’s total health after events that are unprecedented in the modern era.

As healthcare pioneers, HealthEdge understands the challenges of turning an idea into a real-world solution. Even some of the best ideas need nurturing to help them evolve. That’s why we started the HealthEdge Innovation Lab. We believe every idea should have the chance to grow and every innovator should have a place to help them make that happen. The HealthEdge Innovation Lab is the next stop in the evolution of an innovator.

The HealthEdge Innovation Lab offers digital health disruptors a place to develop, test, and evolve their ideas by providing access, education, and support.

Access – We help startup and early-stage companies mature and grow their businesses through access to:

• Client database
• Marketing
• Research firms
• Co-development

Education – We provide a structured education program that includes:

• Mentorship
• Access to experts
• Agile framework

Support – We nurture and support your unique vision through:

• Ecosystem placement
• Design assistance
• Long-term vision
• Partnership collaboration

Driving Transformational Change

We partner with digital health innovators to revolutionize healthcare and drive transformational outcomes, including:

• Member engagement and satisfaction
• Cost reduction
• Operational efficiency
• Growth & innovation
• Business agility
• Provider satisfaction
• Data sharing
• Accurate claim payments
• Clinical workflow management

We believe in purposeful partnership

Our vision is innovating a world where healthcare can focus on people. The HealthEdge Innovation Lab supports healthcare pioneers with:

• True partnership designed to help startup and early-stage companies mature and grow their business
• Expertise and mentorship programs to educate and inform on the challenges and obstacles that often confound the healthcare industry
• Deliberate orchestration of services to unravel the tangled web of healthcare ecosystems and bolster long-term vision and goals

Join the healthcare pioneers  

We want to hear how your organization is innovating and disrupting the status quo! Learn more about the HealthEdge Innovation Lab here.

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.