Category: Uncategorized

 

Most buyers of healthcare/health insurance IT are, by nature, risk-averse. There are very legitimate reasons for concern: IT infrastructure is expensive, complex organizations are structurally resistant to change, system implementations are prone to unforeseen challenges, and benefit expectations are difficult to realize.

In summary, a daunting situation!

How do I create a stand-alone ROI from all of that!?

There is a more critical measure than ROI. It is a question of risk mitigation.

The risk of inertia can be many times greater than the risk of embracing change. Competitive market forces and the ever-expanding role of government guidance/oversight are constant. Failure to keep up (by investing in people and infrastructure) is unforgiving, and the price to be paid is steep and sometimes fatal.

Key market-drivers that if not sufficiently addressed (and thus high-risk items) include:

• The underlying foundation migration of B2B business that is becoming more C2C member-centric
• The data and process challenges associated with payer/provider integration
• Overall transparency demands while adhering to privacy requirements
• Constant growth and change of regulations and compliance

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.”

How do I minimize the risk of “Transformation Supported Through Big IT Investment?”

First, there must be a recognition that this is not just an IT initiative. Forward-looking, well-defined, and measurable strategic business objectives must be clearly articulated.

Second, the rollout of an operations transformation plan that includes people, process support (and yes, underlying technology) MUST be developed and aligned with strategic objectives.

Third, while the effort is large, segmenting into integrated, bite-sized chunks is essential for buy-in and monitoring activities that all constituents won’t necessarily embrace.  Some of these bite-sized chunks might include:

• A listing and prioritization of key foundation-based (versus transaction-driven) transformation goals
• An agile/collaborative model that acknowledges all key stakeholders and does not let perfection get in the way of progress
• The development of a new company approach, where the benefits of the transformed environment can be both realized (due to fewer legacy barriers) and identified by wary stakeholders

In summary, acknowledging and developing the framework to measure both the tangible and abstract rewards associated with risk mitigation (versus a singular focus on the “supposed hard numbers of ROI”) will provide a much better mechanism for developing and recognizing the benefits of the investment value proposition.

Those working in health plan operations are always in the fury of the moment. They are focused on what is the next emergency. How many people is that going to take? When are they going to deliver? No matter their title, the real job is firefighter and janitor; because they are relied on to put out the fires, mop up the mess, and do whatever it takes to make their customers happy.

Health plan operations, especially at smaller plans with limited resources, are pulled in a million directions while also continually searching for ways to reduce costs per member per month (PMPM) to administer their business. Health plans tend to use report-based managing in a very reactive manner, but they could immensely improve their business operations and cost savings if they took a proactive approach.

From the technology side, health plans see hands on a keyboard as a key factor that increases PMPM. Health plan managers will agree that keystrokes cost money. And every time a health plan puts a new person into the system, it costs money. It costs money from a human resources perspective and a data quality perspective; because the most significant chance of introducing error into a system is through the people using the system.

So, from a systems viewpoint, health plans want to lessen the chance of human error. That is why automation is so important.  Automation that empowers the business user to reduce PMPM and increase quality is critical.

When it comes to automation, and increasing quality, one way health plans can do this is through automated-based testing; you never want to test in production when it’s too late to find out if something is wrong. Business user automation through imports, exports, and auto-reprocessing provide a low-cost/ high-quality solution to this problem. When health plans are looking to lower PMPM, they need to make informed decisions. The flexibility to model production transactions in a test environment will allow health plans to uncover what changes could save costs or generate revenue for the health plan.

To successfully reduce PMPM, health plans need a flexible system that does not require a sophisticated IT function for configuration, testing, and accessing real-time data. One that empowers the business user through automation to drive decreasing costs and increasing quality.

Payers are increasingly incorporating social determinants of health (SDoH)— biology and genetics, individual behavior, social environment, physical environment, and access to health care and health insurance—into their members’ health predictions and working together with providers and community resources to fill these gaps in non-clinical care.

However, we still do not have a standardized way of collecting this data, which creates challenges. Furthermore, although it has been proven time and time again that payer and provider collaboration improves care, some are still hesitant to fully collaborate. Thanks to the fee-for-service history, where providers depended on high-volumes, these two sides of the table can often be at odds.

When it comes to value-based care and SDoH, payers and providers benefit from breaking down silos, collaborating, and sharing information, but the industry continues to work in silos. To address these social factors and improve care, data must flow freely between payers, providers, members/patients, and community resources.

Sharing data and analytics can help with SDoH and understanding how it impacts high utilizing members. Bringing data systems together will improve payer and provider collaboration, enable better information exchange, improve quality of care, reduce costs, and provide much-needed transparency across the healthcare ecosystem to manage patient populations.

Health plans must have the tools and technology to collect the SDoH data, share the data, and develop and agree to Key Performance Indicators and take ownership of the scorecard that determines success. And, payers must leverage value-based models to encourage physicians to identify SDoH gaps and create goals or incentives around them.

Payers and providers who take a holistic, preventative approach to members’ care make an enormous difference in an individual’s health and well-being. To that end, SDoH are becoming as important as medical record information. While many payers are down the road with SDoH, the healthcare community in general still has much work to do. Continued partnerships with community organizations and other payers/providers will go a long way to address SDoH.

Health plans know that better member engagement can lead to improved health behaviors as well as enhanced customer satisfaction. That is why they are investing in creating a meaningful member experience.

Enhanced customer satisfaction leads to improved star ratings and other scores, boosting a plan’s ability to attract and retain new members and enabling them to maintain a competitive edge over the challengers in their markets.

While health plans have begun to embrace innovation and many have launched digital transformations over the past several years, these efforts are highly dependent on access to accurate, real-time data. Without it, even the most innovative initiatives to boost member engagement and satisfaction will fall flat. Up-to-the-minute data unlocks critical insights into why, when, and how to engage and interact with members.

Clear communications and the prerequisite ability to provide current, complete, and accurate information to quickly address and resolve issues are crucial aspects of creating a meaningful member experience. If an organization does not have access to the most up-to-date data, they risk not only missed opportunities for interaction or intervention, but critical communication breakdowns with members and other stakeholders. Access to real-time data and analytics allows health plans to quickly interpret and share information, allowing for faster and more effective communication, driving more informed decisions, and actionable next steps.

Health plans also need clear, real-time insights to identify where they can improve and where they should focus their time and effort. If an organization invests money and resources implementing member engagement tools and time bolstering its offerings, it is crucial to track how these efforts are performing with their membership.

With legacy systems, the integration of data sources with today’s analytics and engagement tools can be cumbersome and expensive and neutralizes a plan’s ability to proactively make improvements that impact member satisfaction.

Leveraging access to comprehensive, real-time data is one of the keys to health plan success in today’s world. It enables them to engage more meaningfully with their members, collaborate more effectively with their providers, identify opportunities for continuous improvement, measure the results, and ultimately help their members actively engage in their care and achieve healthier outcomes.

There are several critical considerations for payers looking to build top quality, high-performing and competitive Medicare Advantage plans.

Communication is Key to Success for Acquiring and Retaining Medicare Advantage Members

Ongoing communication is critical to successfully address members’ needs.

“Open Enrollment gives Medicare Advantage (MA) members the opportunity to experience their health plan and decide if another plan better meets their needs. Loyalty to a new plan is tested by these early experiences. This makes it more important than ever that health plans ramp-up the educational efforts to clearly communicate their benefits to help members make the right choice for them initially.” – Deft Research.

Communication needs to be bidirectional, and the ability to stimulate this engagement is imperative. For MA members, satisfaction increases when they feel well-informed and engaged in their healthcare process.

This is also true for healthcare organizations. Silos still affect payers’ and providers’ ability to maximize interdisciplinary approaches to complex issues. It’s the old adage, “One hand doesn’t know what the other hand is doing.” All the data in the world cannot reduce duplicated efforts or missed opportunities to engage the provider or MA member. Payers must provide real-time, actionable data to their MA provider networks and the providers must use the information to improve patient outcomes, leverage new reimbursed benefits and lower costs.

Supplemental Benefits are a Necessity to Managing Social Determinants of Health

Payers and providers are making it a top priority to tackle social determinants of health (SDOH) for better population health outcomes. Many MA health plans have taken advantage of CMS rules regarding new reimbursements addressing SDOH by introducing supplemental benefits and that address “whole life care” and not just short-term medical needs.

Ultimately, addressing SDOH can help minimize or eliminate gaps of care, especially for high-risk, high-cost MA members.

How do you address these disparities? Offer care at the local level. Plans offering care solutions that address isolation, food insecurity and environmental factors impacting chronic conditions help provide MA members with alternative solutions and community resources to fill care gaps. Simple solutions such as carpet cleaning and air conditioners for asthmatics, Meals on Wheels for isolated seniors, and transportation to doctors’ appointments make a material impact on quality of life, as well as overall well-being for large demographic groups. Medicare Advantage plans need to empower their members to engage with new supplemental benefits and create benefits for SDOH that are left unaddressed.

Is Technology the Silver Bullet?

From interpreting data to improving patient engagement, technology plays a meaningful role in building a successful MA plan. The implementation of AI, voice assistance, telemedicine, and other technology also requires the consideration of member communication, readiness for change, and lasting, meaningful engagement. Leveraging automation and data to deliver impactful care pathways is not one size fits all. Though AI is still in the early stage of use in healthcare, the potential impact is promising. The ability to incorporate new, alternative benefits rapidly in response to member needs and changing regulations also requires a modern technology infrastructure.  Payors who cannot keep up with constant change will inevitably be left behind.

I’m excited to see how Medicare Advantage plans continue to improve care and create new opportunities for their members.

For health plans with limited resources, cost pressures continue to weigh heavy. Outdated technology and siloed systems can adversely impact operational efficiency, create significant processing challenges, drain productivity, and ultimately impact the bottom line.

Health plans require analytical insight into the business in order to identify trends and make well-informed decisions. However, the data is often on separate legacy systems with varying data structures, making it difficult to merge data for month-over-month, year-over-year analytics across the portfolio.

The ability to provide robust, comprehensive data to customers and trading partners can be an enormous challenge for health plans.

For example, I worked with a regional plan in the Mid-West with Commercial, Individual, Medicare Advantage, and Medicaid lines of business.

The plan wanted a way to track claims applied to member deductible (Out-of-Pocket), see the specific authorization used when the claim processed, and calculate how many visits a member has used on a limited service such as physical therapy without counting line-by-line. They also wanted a way to easily share that information as well as simplified balance due, credit amounts, and other billing details with their members.

The plan’s legacy platform did not offer a reporting solution with real-time operational insights. Instead, their reports included old data that was useless when trying to provide meaningful information. Not all information in the system was effective date-driven, and some critical data was only point in time, resulting in financial errors and incorrectly processed claims.

Without complete, robust, and accurate data, all in one system, errors will continue. Health plans need a reliable system that is easy to maintain and provides operational data for reporting and analytical dashboards to make critical business decisions.

To successfully compete in today’s market, health plans need next-generation technology and access to real-time analytics that provide insights that enable transparency inside and outside their organizations.