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Many people have said that there has been more change now than ever before within the healthcare industry. However, if one reviews history, healthcare has been this way for decades. One thing we’ve counted on is that this is an industry of change. There are constant regulatory updates and new trends and advancements. Organizations must have the tools and resources to effectively manage the constantly evolving landscape from a technology perspective and a staffing perspective. Change is good and offers job security!

One of the most pressing healthcare security challenges that IT leaders face in this changing industry is how to keep information secure. In fact, in a recent survey of 245 healthcare IT executives, 43% of IT leaders say keeping information secure is their top challenge. There is a lot at stake for everyone across the company. Not only is there a risk of cybercriminals gaining access to sensitive information if there is a security breach, but an organization may also face hefty fines, and its board members could have personal liability. It takes ongoing training to help people at all levels of an organization understand the importance of remaining diligent.

The Importance of Addressing Healthcare Security Challenges

IT teams should always be looking for ways to continually improve security protocols and policies. Phishing attacks still account for a high volume of security incidents.

Regular phishing tests are a proven means of providing ongoing training to change behavior. Even poor results from phishing exercises provide awareness of where supplemental training may be necessary. Approaching training from the perspective of protecting not only company assets but also personal assets at home helps reinforce learning and change behavior, enabling employees to see a tangible personal benefit.

From a personnel perspective, there is significant competition for qualified candidates and employees, and security professionals are certainly in high demand. The loss of a key security expert can be devastating. Turnover can negatively affect a team, and recruitment and training each new hire can be costly. CIOs and other technology leaders must not lose sight of the importance of employee retention.

Even with the most sophisticated technology, no organization should bank on its security being impermeable. It is often stated – “it’s not a matter of if, it’s a matter of when.” There will be incidents, so it’s crucial to have the right protections in place and the ability to react, respond, and resolve quickly and effectively.

Successful health plans are focused on expanding membership, increasing revenues, and controlling administrative costs. However, administration costs attributable to outdated technology and manual processes result in one of the highest sunken costs in healthcare.

Outdated Technology in Healthcare

Health plan operations, especially at smaller plans with limited resources, are pulled in a million directions. They are continually searching for ways to innovate and improve operational efficiency while reducing costs. However, as administrative expenses increase, tighter budgets become, and less money is available to reinvest in crucial differentiators and forward-thinking initiatives. Outdated technology in healthcare and siloed systems can adversely impact operational efficiency, create significant processing challenges, drain productivity, and ultimately impact the bottom line.

For example, Michigan-based McLaren Health Plan’s outdated 30-year-old technology was resulting in a zero percent claims auto-adjudication rate. McLaren’s legacy solution was clunky, hard to configure, not user-friendly, and not scalable.

As Mike Comick described in a blog post, “At some point in time, the amount of road remaining for ‘investment modernization’ of existing organizational structure, use of data/business intelligence, and legacy technology is depleted. Ultimately the risk of minimal maintenance, or worse, doing nothing, is by far greater than ‘taking the big transformational jump.’”

McLaren agreed, as its Vice President of Business Information and Operations, Sara Mavredes, said, “We wouldn’t be in business if we didn’t make a change.”

McLaren decided that it needed to implement new technology that would allow the business to work more efficiently and intelligently, and that would provide it with the margin to implement new strategic initiatives like customer service, care coordination, new lines of business, and other innovations.

McLaren implemented next-generation technology and gained flexibility, transparency, and performance, critical for its success.

Continue reading this case study to learn how HealthRules Payer® enabled McLaren to respond to industry changes, reduce costs, increase efficiency, gain an edge over the competition, and more.

What are individuals called in a health plan? Members. What are people called when they meet with a provider? Patients. What is an individual person referred to in any other industry that uses end-to-end solutions? Customers.

The “unique” needs of a member vs. a patient in the B2C healthcare or health insurance setting aren’t really unique at all. At the end of the day, these needs are customer needs.

Not surprisingly, with the growth of government-based healthcare programs like Medicare, Medicaid, and Individual/Exchange lines of business, the migration from a dominant employer-based “customer” Business-to-Business (B2B) relationship has transformed and become more of a consumer-driven Business-to-Consumer (B2C) environment.  Health plans must find ways to treat members as customers and look at how to provide an end-to-end solution that best serves their needs.

How can different types of health plans cope with the consumer-driven B2C healthcare growth?

There are different paths to get there as plans can use their inherent strengths to meet this changing demand.

For larger plans, their respective budget capacity (and subsequent ability to invest in scalable solutions) have enabled them to heavily invest in front-end “consumer-experience” technology. While mid-sized (generally regional) type plans, the closer relationships between payer and provider and the willingness or, in some cases, equity structure (health plans that are owned or closely affiliated) provide a mechanism to more readily share data and collaborate on end-to-end processes, allowing members to enjoy a combined experience from a single entity.

Regardless of the means to “get more consumer-driven,” the common foundational technical requirement investment are back-office applications that are interoperable, data-integrity true, and secure. To move to the next generation of where healthcare is going, health plans must modernize their core system.

I joined HealthEdge seven years ago when, like most startup organizations, we were primarily focused on our mission, products, and exciting our customer base. At that time, there was a lot of work in front of us to build out our products and execute our mission, leaving our culture unintentionally to come in second. We knew we wanted to become an employer of choice, and so in those early days, we set about building a foundation of clarity, trust, and consistency.

This strategy was a commitment to the long game and wasn’t always linear, but we took meaningful steps forward over the years where we could action change. Progress was slow until Steve Krupa joined the team as Chief Executive Officer. Under his leadership, we began reflecting on our culture and seeking feedback for improvement. We recognized the opportunity to make a positive shift in our company culture and began to see the correlation between customer value and employee satisfaction. This journey led us to start talking openly about the culture we wanted, acknowledging areas the needed focus, and regularly solicit feedback through employee engagement surveys.

Asking for feedback is the easy part; the hard part comes when you need to take action on the feedback. We chose to be open and honest about the data despite the fact we were not proud of those initial results. We spoke continuously about what we heard, what we interpreted and encouraged people to ask questions and help us develop solutions. We formed an employee council dedicated to providing a forum for a live employee voice, not just one that lived through the survey data.

Building a winning culture is not about quick wins. It’s not about ping pong tables or creating a cool looking office. It’s about a shared sense of purpose and building an organization that supports, encourages, and empowers excellence. It’s about building a community to which we can all belong and contribute. When everyone is positioned to feel connected to the company’s collective success, it’s a huge motivator.

This is a journey, not a destination. While we have been named a Top Place to Work and a Best and Brightest organization, the work is definitely not done. We are only here because our employees were willing to share feedback with us along the way and co-own this culture. We are thrilled with our shared success but know our journey continues, and as such, we will continue to ask for feedback, listen to our employees, and work together to continue to innovate on a great employee experience.

Regional health plans have generally flourished in the respective local markets that they have served. However, regional health plans only “extended” as far as the affiliated providers employed by the delivery system in a staff model or contracted in a group model.

Today, competitive pressures from larger plans offering statewide (or beyond) employer group networks that meet their overall needs have put regional plans at a disadvantage and forced them to look at new ways to grow their business to remain competitive.

How do regional plans respond? Regional plans should continue to leverage the collaborative payer/provider relationships that exist in the original service area. With these relationships they can maintain ongoing optimization of collaboratively developed value-based care, enhance use of integrated payer/provider data integration, and further develop complementary business processes that can help to improve the customer experience.

Regional health plans should also focus on transforming business practices and underlying technology that can easily configure to better position and police relationships beyond the original service area. Where strategic business objectives might be slightly or significantly different between payer and provider, functions that were historically collaborative in a shared regional market are potentially competitive in an expanded one.

Some of these functions include:

• Overall provider network management
• Enhanced provider reimbursement / contracting
• Customer-facing call center and self-help support to an increasingly disparate customer base
• More policing of care/utilization management capabilities

The transformation curve is significant. The time required for planning, general design, eventual investment, and execution requires buy-in from all stakeholders. The risks are high for not positioning for growth. The risks (and poor results) are exponentially higher for organizations that fail to fully account for the overall investment required from underlying/foundational core systems integrated with other value-added applications/utilities.