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If a health plan takes the DIY path, what happens to its knowledge resources over time? In the “build” scenario, an organization owns the product and every challenge that comes with it. If something breaks or becomes obsolete, will the resources to keep it up be available? Will the organization be poised to chase innovation as its competitors are sure to do? Can the plan command the talent in the marketplace to keep its unicorn solution operating at peak value? When development talent and expertise erode, it will mean trouble. The expertise to train users and provide day-to-day technical support is critical to long-term success.

Management should prepare for an ongoing tide of integration requests. Contracting and partnership for these becomes a perpetual administrative function – another cost often overlooked.

As a health plan executive, ask yourself when considering the “buy or build” argument whether there is already a mature solution on the market that will do the job. In healthcare, smart vendors have already developed an interoperability infrastructure necessitated by recent government regulations. Look for this kind of commitment from any vendor in your own industry because it could make buying a solution even easier – it certainly does in the case of healthcare.

Executives should weigh what they hope to gain from building a proprietary solution when the hard work has already been done for them. Will this give them a competitive advantage? Do they have a realistic view of the risk and ROI? Can they invest sufficiently in the initial architecture to build a comprehensive solution?

We are a nation of do-it-yourselfers who take pride in self-sufficiency, but knowing when to tap the real experts is a strength, not a weakness. Remember the adage to “do only what you do best.”

Asking hard and far-reaching questions now will help you avoid Big Fail #5.

Portions of this blog post are excerpted from Ashish Kachru’s Forbes article “Why Execs Should Avoid The DIY Software Trap.” Ashish is President and General Manager of Altruista Health.

In HealthEdge’s recent survey of 220 health plan executives, respondents cited increasing member satisfaction as their top strategic goal for 2021. When asked what steps they plan to take to achieve their goals, “improve engagement strategies” topped the list.

Laser-focused on customer service and outreach, payers are looking for new ways to enhance the member experience by leveraging digital technologies that enable improved communication, real-time data sharing, and personalized services, while increasing operational efficiencies.

Investing in digital health is on the rise. Rock Health reported, “It’s been quite a ride this past year watching digital health catapult from a niche sector to a mainstream market. The first half of 2021 closed with $14.7B invested across 372 US digital health deals with a $39.6M average deal size.”

The report added, “Even at its six-month mark, 2021 already surpassed 2020’s overall funding record.”

With the emergence of cloud-computing, API capabilities, artificial intelligence, virtual health, mobile apps, and more, the healthcare industry has seen a boom in digital technology startups with solutions aimed at improving care and lowering costs.

The digital disruption puts tremendous pressure on payers and providers to invest in next-generation technology or get left behind.

In this environment, health plan executives should be especially wary of vendors with “DIY” applications who are trying to enter their industry for the first time. Over-confident players with simplistic approaches underestimate the industry’s intricacies around lines of business, regulation, data, clinical practice, financial dynamics and consumer trends. Decision-makers should skip entities with a core focus elsewhere or who are spreading themselves across too many disparate businesses.

Vendors with success in other segments of the economy aren’t guaranteed the same outcomes elsewhere. No business should settle for being someone else’s experiment. That’s key to avoiding Big Fail #4.

Don’t miss the final installment of the 5 Big Fails of DIY Software. The last segment talks about the big-picture, long-term costs associated with your DIY platform.

Portions of this blog post are excerpted from Ashish Kachru’s Forbes article “Why Execs Should Avoid The DIY Software Trap.” Ashish is President and General Manager of Altruista Health.

Here at HealthEdge, we have a rich history of hosting highly interactive and engaging customer conferences. It’s always been one of my favorite things we do because it allows us to bring our HealthEdge community of customers and partners together to exchange ideas, share lessons learned and talk about where we see the future of healthcare going.

Due to the pandemic, this year we hosted a virtual customer conference, IMPACT 2021, and it was an amazing event. We welcomed nearly 200 customers, ranging from those who have been with us since our inception to those who recently joined the HealthEdge community through our acquisitions of Burgess and Altruista Health.

During the four-hour session, we shared our vision of leading the digital transformation of healthcare through best-in-class products and an integrated platform, and they shared with us their plans, challenges and hopes for the future.

The purpose of this article is to share with you some of the highlights from my keynote address and encourage customers and prospects to reach out to their account managers and engage with us. Together, we are transforming the business of healthcare. I invite you to join us on this incredible journey.

Our Community is Growing

As our customers expand into new markets with new lines of business, we too have expanded our scope of offerings. After finding the right capital partner, Blackstone, in 2020 to help support our ambitious growth plans, we were able to bring into the HealthEdge family two businesses, Burgess Group and Altruista Health.

These additions brought more than just powerful, best-in-class products in the areas of payment integrity and clinical care management. They brought incredible teams of talent, packed with innovative ideas and best practices from across the health plan industry.

Bringing these bright minds together to plot our course of how the solutions will work together to drive incremental value for our customers has been nothing short of amazing.

Since then, we’ve double the size of the company both in terms of revenue and employees.  Today, we work with 90 companies, including national and regional health plans, commercial and government plans, BlueCross BlueShield plans and specialty claims processing organizations. We cover more than 35 million lives and virtually every line of business.

Building a Bright Future: For our Customers, with Our Customers

Our mission is to empower our customers to drive higher levels of automation and efficiencies while also reaching higher levels of member and provider satisfaction… and ultimately achieving growth. We accomplish this by focusing on our five core principles:

1. Optimizing business value for our customers and employees
2. Facilitating cross-functional collaboration
3. Driving continuous process improvement
4. Following first-principles thinking
5. Enabling engineering excellence on behalf of our customers.

In fact, everything we do is for our customers. We’ve built this company for our customers, and the collaborative culture we share with them has been the key to helping us all solve some of the biggest challenges facing healthcare today. And I believe if we continue to focus on these core principles, we are uniquely qualified to lead the transformation of healthcare together.

The Journey of Transforming Healthcare

As health plans expand into new markets and healthcare consumers demand more personalized services, the need for automation and transformation has never been greater. At HealthEdge, our overarching product strategy centers on two main themes: (1) deliver best-of-breed solutions across our customers’ businesses that can (2) easily integrate together accelerate time-to-value for our customers. Let’s take a closer look at what we mean by these two themes.

Deliver best-in-class, individually excellent solutions.

• Offer the finest claim system that gives our customers flexibility and agility to run their business – that’s HealthRules® Payor. We’re expanding our capabilities to support things like value-based care, expanded benefits design, and advanced integrations.
• Offer the best claims editing and pricing rules engines to facilitate more accurate claims and higher payment integrity – that’s Source®.  Our Burgess team does a phenomenal job of maintaining the most up-to-date payor rules and pricing engines.
• Offer the best care management system that empowers clinical teams to provide optimum care in the most cost-effective manner – that’s GuidingCare®. Our Altruista team is obsessed with coming up with new ways for clinical teams to monitor the quality and utilization of care services to generate the best outcomes.

Deliver an integrated suite of solutions.

By having all three platforms under one roof and our solution teams working closely together, we can more quickly build seamless connections and workflows that can:

• • Share more data in real-time for better insights and informed decision making
  • Drive smarter business process that take the burden off administrators and clinical resources
  • Generate extreme efficiencies, better care and more satisfied members and providers.

A Look Ahead

With our wide range of customers, our solutions exist in a wide variety of ecosystems. But as we look ahead to our product strategy for the next few years, there are four common denominators that will guide our product investment decisions:

1. The need for end-to-end automation. The manual-intensive business processes that exist across health plans and providers are placing undue cost burdens that threaten our ability to deliver quality care in the future. We’re rethinking every process and finding new ways to automate the business of healthcare.
2. The demand for real-time data. Being able to make more informed administrative and clinical decisions is dependent on being able to access the right data at the right time. We will continue to expand access to all types of data through advancing our API framework.
3. The move to expand into new markets. Helping our customers quickly and confidently move into new markets or grow their lines of business requires flexible solutions. We’re focused on increasing the configurability of our solutions so our customers can adapt faster to changing market conditions.
4. The shift to value-based care. From setting up value-based arrangements to accurately pricing value-based claims, we’re focused on making it easier for our customers to compete and win in value-based and risk-sharing arrangements with greater access to the clinical and operational data they need.

Beyond the Highlights

Packing a 45-minute keynote address into one brief article is an impossible task. We have so many innovative things going on across our business and across our customer base. I hope that you will stay tuned for more posts in the coming weeks as I dig deeper into each component of our strategy and our product leaders lay out their respective roadmaps.

For now, please know that we are grateful for the level of energy and enthusiasm we receive from our customers every day, and we are encouraged by all of the innovative ways they are using our solutions to grow their organizations and make healthcare better for everyone. Thank you to every one of our customers, partners and team members who made IMPACT 2021 such as success.

“63 percent of executives report the pace of digital transformation for their organization is accelerating … Big changes today require bold leadership – and prioritizing tech.”– Accenture Research Global Survey 2021.

The healthcare industry is undergoing a period of digital transformation, forcing payers to prioritize their modernization efforts.

As a colleague at HealthEdge, Len Rosignoli, VP of Customer Success, recently noted in a blog post, an increasing number of health plans see value in using technology to meet their business strategies. “That’s why we’re seeing an increased focus on aligning IT and the business – the partnership has become even more essential,” he said.

But without a clear strategy, payers risk wasting time and money building or patching solutions that provide a quick fix for immediate needs, but cannot support the future of digital health.

Even worse, history indicates that when decision-makers insist on building or patching their own solutions, they are likely to underestimate the cost and timeline.

Research shows that among 1,471 information technology projects studied, the average cost overrun was 27 percent, a figure pushed higher by the one in six projects that spiraled completely out of control. The worst of these saw cost overruns of 200 percent and schedule delays of 70 percent. Researchers say IT has a disproportionate number of runaway projects.

There are other costs to consider. A firm developing a proprietary solution absorbs the entire cost of development, where vendor solutions can distribute development costs and innovations across multiple customers. Since a vendor solution has a much shorter and safer timeline, it offers greater cost predictability over time.

It’s easy to be caught up in your do-it-yourself (DIY) ambitions, but being realistic about costs and deadlines may lead you to choose the right vendor instead, avoiding Big Fail #3.

Check out the #4 Big Fail of DIY software in this space soon. Hint: It’s all about the perils of trusting newcomers to healthcare.

Portions of this blog post are excerpted from Ashish Kachru’s Forbes article “Why Execs Should Avoid The DIY Software Trap.” Ashish is President and General Manager of Altruista Health.

We’re two ears, one mouth when listening to customer issues. We are fortunate to work with a variety of health plans ranging from large nationals to small regional plans.

Reducing provider abrasion is top of mind for all plans, particularly for the regional health plans that require cooperation with the providers in their communities to survive.

GuidingCare has made a lot of improvements in provider satisfaction for our regional plans. A big complaint from providers is the time it takes to receive an authorization from a payer. Our prior authorization portal helped solve this issue. With most of our plans using this technology, more than half of the authorizations get auto-approved without human intervention. Providers spend less time waiting for answers with the prior authorization portal; they quickly receive the information they need.

One of our customers is a small regional plan in a state where national plans have a significant presence. Provider satisfaction is critical to ensure our customer can remain competitive. The regional plan came to us with ideas for how to improve the authorization portal. They wanted to bring together their organization, their local health system, and the GuidingCare team to create the best authorization portal in the industry.

As a technology vendor that values our customers, we knew it was an incredible opportunity to hear directly from the health plan and health system to find out what’s important to them then work together to see how our technology can meet their needs.

While this collaboration was not part of the scope of work or implementation plan, we were all in.

We spent three months with a tiger team and built an entirely new best-in-class product. We’ve sold six so far this year, and our customers are finding tremendous success.

For the customer who influenced this innovation, 80% of their authorizations come through the portal, and the majority are automatically approved. They have saved more than 5% of their overall care management budget.

These savings were made possible by listening to our customer’s feedback and innovative ideas, then working together to build them. Collaborating with our customers is a formula for success.

Social Determinants of Health (SDOH) have a significant impact on a person’s overall health. Payers and providers are coming to realize that they can manage risk with highly targeted intervention programs while reducing unnecessary care.

However, managing and predicting SDOH among members continues to be a top challenge among health plan leaders. Furthermore, in a recent survey of 3,000 consumers, when asked if a health insurance company, primary care physician, or a specialist directed them to a community resource to further support their care, 72% of consumers said no. Yet, for those who were referred to a service, 81% engaged with the treatment or resource once they knew it was available. Member engagement is key to addressing SDOH, but there is a communication breakdown.

Speed, efficiency, and access to real-time information are required for outreach to connect the right members, to the right treatment, at the right time. Users do not want to have to log into multiple different systems to gather the data they need.

Altruista Health is on a mission to help our customers positively impact members’ health by focusing on proven methods of increasing their engagement. Our open interface supports API-led connectivity and seamless integration with other tools and technology.

For example, we have analytics with the Chronic Illness and Disability Payment System (CDPS), a predictive risk model that analyzes diagnostic and pharmacy data to identify and group populations into more than 60 risk categories.

Our GuidingCare platform also integrates with Aunt Bertha and Healthify, the nation’s leading social services search- and- referral platforms that enable users to quickly access comprehensive, localized listings for hundreds of programs across the country.

Payers and providers are looking for technology solutions to make interacting and engaging with patients easier. Our goal is to make our solutions easy to use for everyone, no matter their experience level, so our customers can stay focused on their business and improving health outcomes for members.