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At HealthEdge, we frequently hear from health plan executives struggling with homegrown legacy solutions that have become obsolete. Their users have developed a hodge-podge of manual workarounds to accommodate a growing set of deficiencies, right down to Excel spreadsheets and double-entering data into disparate systems. Add to that the complexity of the healthcare ecosystem today and you have a recipe for dysfunction.

Industry consolidation is a growing trend in the payer space today. The steady stream of mergers and acquisitions results in multiple systems, point solutions, and dissonant architectures jamming up the flow of information in many organizations. With legacy systems, outdated technology and latent data and delays, the quality of care suffers, backlogs pile up, and opportunities to support innovation evaporate.

As the Everest Group noted in a blog post, “The healthcare payer industry is plagued with notoriously old infrastructure. While healthcare payers are working to increase data transparency, offer member-centric solutions, and adopt a value-based care model, they’re obstructed by high reliance on dated, disconnected and non-interoperable systems.”

The disjointed systems and manual processes waste time, introduce manual errors into workflows and can eventually destabilize the software program. Staff and customers eventually bear the brunt of this.

Knowing when to put your legacy system out of its misery is a critical multiplier for success. That’s why letting it hang on too long is Big Fail #2.

Portions of this blog post are excerpted from Ashish Kachru’s Forbes article “Why Execs Should Avoid The DIY Software Trap.” 

Much of the GuidingCare product roadmap has been influenced by our customer’s experience.

We have something called ride alongs, where we go with our clients out into the workplace and see how they use our product. These visits have greatly influenced our product roadmap; we identified significant capabilities that we needed to implement by watching real people work in the real world.

One of those influences was our award-winning Mobile Clinician app.

Whenever you’re driving, and your phone loses connection to a mobile network, think about the people who live there. And there are a lot more places than people think, spanning from remote locations in Hawaii to the rural mountainous regions of the Southeast. We even did a ride-along with a customer in a part of the Navajo Nation in the middle of the desert with no service.

While out in these remote areas, if a clinician is visiting patients and can’t go online to access a web service like GuidingCare, they need the ability to work offline in order to best serve these patients. The Mobile Clinician app solves this challenge. The app allows field clinicians to visit with patients in their homes or communities and use on- or offline on mobile devices to perform care management functions. The offline capability is especially valuable in serving areas without dependable internet or cellular service, where populations need care and social support resources.

In addition to capturing demographic data, conducting health assessments, and making referrals to social services, among other things, clinicians can also build care and service plans in the Mobile Clinician app, which is another process that our ride-alongs helped us improve.

We wanted to reduce the number of clicks that it takes a clinician to build a care plan, so the technology did not get in the way of valuable face-to-face, human interactions with the patient during the visit. We made huge improvements, resulting in single-click care planning—now clinicians can finalize care plans without interruption.

I’ve been with Altruista for more than eight years and was drawn to the company’s mission of improving care through promoting member engagement and access to care. The Mobile Clinician app helps communities overcome barriers to accessing care and better health outcomes, regardless of location.

More than ever, health plan executives see their IT and business strategies as deeply intertwined:

According to Accenture Research Global Survey 2021, 83 percent of IT and business executives say business and technology strategies are becoming inseparable – even indistinguishable. Furthermore, 77 percent say that their technology architecture is becoming critical to their organization’s success.

Yet, for anyone leading an organization, cost is always a top consideration.

What executive hasn’t asked themselves at some time, “Couldn’t we just build this software ourselves?” It’s not unheard of to wonder whether in-house development will deliver a less expensive custom product. These decision-makers should heed the cautionary tales of “build” decisions that resulted in longer timelines, cost overruns and poor results. No less than General Electric embarked on an ambitious in-house digital transformation that quickly became mired in organizational dysfunction and conflicting priorities that have dragged on for years. I believe there are many more “build” stories that never generate headlines because they remain internal failures that no one wants to discuss.

The scenario is even more complicated in healthcare.

When Altruista’s parent company, HealthEdge, recently asked 222 health plan leaders what steps they plan to take to achieve their organizational goals this year, 59 percent said they plan to modernize their technology and 50 percent plan to make a significant investment in innovation, up from just 19 percent in 2018. It’s clear they see the importance of technology investment, but will they choose wisely?

As the president of a high-tech company serving health plans, I can tell you that our customers operate in one of the world’s most challenging environments. Reinventing the wheel just doesn’t make sense, especially in ecosystems like healthcare that are defined by flux. I would advise organizations in any industry to stay focused on their core mission. Developing software is not the strong suit of anyone outside of technology, and executives are advised to rely on the expertise of people who have devoted their careers to software development.

In an era of highly specialized knowledge, it only makes sense to trust the innovators who have purpose-built a platform for your exact needs and who will continue to stay ahead of the market. Therefore, the key to avoiding Big Fail #1 is to stay in your lane.

Portions of this blog post are excerpted from Ashish Kachru’s Forbes article “Why Execs Should Avoid The DIY Software Trap.” 

The health insurance industry is constantly evolving with the introduction of new regulations, the need to adopt value-based reimbursement (VBR) models, and changing customer expectations. Innovative health plans are transforming their business operations — discovering ways to efficiently tackle these challenges and better meet market demand while reducing costs.

Business transformation requires your organization to objectively examine the people, processes, and technologies that drive your core business, with a focus on automation.

A recent survey revealed that competitive pressures (39%), lack of alignment between IT and the business (39%), followed by member satisfaction and managing costs (37%), are the top three challenges facing their organizations today. This is a notable shift from a 2018 executive survey, where lack of alignment between IT and the business ranked at the bottom (22%). Payers are waking up to the fact they must meet consumer demands to remain competitive, and IT must actively participate in achieving these business goals.

Changing market dynamics continue to encourage health plans to grow their businesses, develop new services, increase membership, and ensure a positive member experience. To achieve these goals, the first step is to find a modern technology that helps plans quickly adopt new business models and automate processes to achieve optimum operational efficiency.

If your organization wants to take the first step in the transformation, ask yourself a few basic questions:

Can my current system:

• Improve my member satisfaction?
• Improve my claims adjudication rates, speed, and efficiency?
• Help me launch new plans/benefits/services in a matter of hours?
• Help me easily expand into new geographies?
• Help me reduce my claims backlog?

If you answered no to any of the above questions, your first transformation opportunity might reside in your core administration system.

Legacy core administration systems were designed in a different era. Today, members and providers demand to access real-time information online, and plans must be responsive to all inquiries. While many health insurers have made significant investments to modernize and integrate these systems, their architecture does not offer the flexibility and speed needed to succeed in today’s marketplace.

Do not underestimate the need for flexibility. A health plan must be agile enough from a people, process, and technology perspective to proactively embrace new regulations and reimbursement models, exceed customer expectations and develop and introduce new plans/benefits/services fast.

We speak early and often about why we do what we do. We want to help people live the best lives they can, no matter their circumstances. We help care management teams achieve this “why” by offering the latest generation care management system.

It’s all about automation to allow clinical teams to work at the top of their license. For example, our prior authorization portal allows providers to enter a request, and if it passes the criteria, the service is automatically approved without human intervention. Provider satisfaction increases because they don’t need to wait for an answer, and as a result, the care clinicians can spend more time focusing on how they are going to help members live the best lives they can.

When you think about GuidingCare, the name, it should hopefully tell you that it is to guide the care journey—the platform offers evidenced-based next steps the provider should take to ensure the member receives the best care in their journey.

Compliance is another critical piece of care. The Affordable Care Act (ACA) caused the most significant shift in our business. After the ACA, health plans realized that the way to grow their business was through government programs. And, when it comes to government programs, regulations are complex, and compliance has a revenue implication. Take Medicare Advantage (MA), for example. As MA plans seek to grow their businesses, potential members are looking at which plans have the highest star ratings. If a health plan cannot achieve at least four stars in MA, it is very challenging to make it financially.

From the beginning of implementation, we’re focused on compliance. We help the customer avoid configuring their system in a way that would impact their ability to report on compliance, whether they’re NCQA, URAC or have CMS requirements for Medicare Advantage. We help our customers maximize their stars and make sure that they’re successful when they get audited by whatever governing body.

Our customers want to know they’re taking the best next step in the care model, that their people are efficient and working on the things that matter, and that they have the tools for regulatory compliance and reporting. GuidingCare enables all of that, and we’re always enhancing our capabilities.

We have an Interim Final Rule for the No Surprises Act, referred to as Part I. The comment period closed on September 7, 2021.

This is the administrative piece of the No Surprises Act, the federal level law that addresses group health plans and providers’ responsibility to the member for emergency care by an out-of-network provider or facility, an out-of-network provider during an in-network care episode (when the patient is not made aware before the services are rendered), and air ambulance.

Although some states already have surprise billing protections, states didn’t have the ability to reach self-funded employer insurance plans formed under the Employee Retirement Income Security Act (ERISA plans).

At a high level, the intent of this rule is to hold the patient harmless in these situations, without impacting their cost-sharing, as if they were in-network.

The provider and health plan are on the hook to ensure the patient is aware when they are entering an out-of-network situation and must work together to keep the member whole.

For example, let’s say a member goes to an in-network facility for surgery. The member believes all services are in-network, yet the anesthesiologist happens to be out-of-network. If the member is not aware and agrees upfront (consenting) to having an out-of-network doctor perform services, then the claim must be processed as if it was in-network. The provider and the plan will have to agree on a particular payment arrangement or the amount or the rate. Some arbitration and mediation can occur if the provider and the plan cannot come to terms, but there will be no balance billing to the member.

For health plans, there’s a bit more red-tape in the back end to ensure they’re not showing cost share as in-network and that the provider is on board with accepting our payment. Many processes will need to be updated from the plan’s perspective, but the intent behind the rule is important.

Consider this: when you’re in an emergency situation, the last thing on a person’s mind is, “does every provider in this ER take my insurance?” Or, if you require an air ambulance, “Are you calling an in-network ambulance?” That’s why these protections are being put in place.