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So many regulations are intertwined; health plans cannot ignore the ones that may seem insignificant. Every year these smaller regulation changes get bigger. However, there are also advantages of regulatory compliance that can benefit both the health plans and their members.

For example, the industry has been talking about provider directories since the mid-80s, but change was still very slow. The inhibitors to having up-to-date provider directories often moved initiatives for standardizing and updating the processes to the bottom of the priority list. CMS now has the ability to substantially penalize payers whose provider directories are out of date or otherwise inaccurate to the tune of $25,000 per member!

One of the key requirements in the Interoperability Final Rule is the Provider Directory API. This rule, enforceable in July 2021, highlights the importance of accurate and timely information about network providers for Medicare Advantage and Managed Medicaid. Health Plans operating in the CMS markets must take steps to ensure their data and processes to deliver the data are working properly, not just to be compliant but also to remain competitive.

Medicaid Managed Care, in particular, is evolving rapidly. A few years ago, most Medicaid recipients stayed with a fee-for-service Medicaid; they were not pushed toward managed care. Many states now prefer managed care over fee-for-service, as it is lower in cost and also preferred by an increasing number of members, as it provides more options and flexibility.

Medicaid is very fluid. A health plan with a Medicaid line of business must stay in-tune with what CMS is doing and how it interfaces with its state’s specific regulations. In particular, the business processes for Managed Medicaid enrollment can seem overwhelming. Daily full enrollment files are sent by the state, which must be translated into enrollment records that retain a historical view of all changes made throughout.

This deluge of information requires technology that can handle extensive slicing and dicing of the data. The enrollment record changes can impact everything from the available benefits for the member to their primary care provider assignment and even the amount payable for a specific service.

The enrollment data is required by core processing systems and must be viewable and usable by the health plans to properly address questions and other inquiries. Furthermore, these changes are typically time-sensitive, requiring that daily files are processed quickly and accurately and sequentially.

Many regulations are intertwined, some in conflict, some furthering a “cause” or process. The mission of all is to benefit the members, and in most cases, there are advantages of regulatory compliance to the health plans.

For example, health plans that focused on getting an updated provider directory in their claims system and also available to members create a win-win scenario! Members and potential members have the most up-to-date information, and health plans are processing claims without the worry of mass adjustments (or penalties!) down the road.

Everyone benefits!

If an organization is open to change, it will always result in a successful, smoother implementation of new technology.

For those who are reluctant to change, it’s an issue of comfort and routine. Some still want to do things the same way they have done them for the past twenty years because they are familiar with it. They’re in their comfort zone and want to maintain the way they’ve always operated.

I strive to help my customers understand that change is good; there’s a brand-new opportunity to enhance their process and improve how they interact with their system. If they embrace change now, they will be better off years down the road.

In addition, if there is hesitation, it’s often because the client may fully understand the benefit of changing their technology. Sure, the upper management understands, but getting that understanding to trickle down throughout the organization is a challenge. It’s a learning curve. I’ve found that the process goes much smoother if everyone at the organization has a clear understanding of why these changes are happening, what it means, and how it will improve their business.

In my role, I always strive to bridge this gap and help the people that I’m working with understand how our solutions operate and how it differs from their current system. When it comes to upgrades, I know the functionality coming in with newer versions and how it will impact a specific client; so a lot of my discussions show people what has changed between each version and how to use it. Setting up demos is also a great way to help customers identify opportunities and begin to understand the value and where they could see results.

Successful implementations are what I look forward to most. I deal with clients on a daily basis, and I love doing whatever I can to help them succeed. That’s what motivates me.

As health plans continue to compete for membership, I have seen a shift in the market toward a focus on member-centricity. Health plans competing to aggressively grow membership have begun to reinvent their companies by throwing away their old models and using a minimum viable product (MVP) approach that focuses entirely on creating a positive member experience.

This concept was introduced to me about five years ago by a client in the Midwest who had just purchased an existing health plan. They wanted to rebrand this newly acquired business using this approach. They recognized that their current business model was stagnant, but understood they also had a treasure trove of assets in terms of highly skilled resources and technology at their disposal to remake the future. As time elapsed, several other health plans across the country were asking how they could do this.

To increase speed-to-market, this concept centers on a fail fast/fix fast approach. This also aligns well with Agile methodology and helps clients that are challenged from shifting away from traditional waterfall-based delivery. The entire goal of getting into the system is to fail fast, and if the required result fails fast, the client needs to fix the failure through business user-enabled automation and keep the project moving forward— this overall thought is a key aspect of continuous optimization.

The strategy of the most successful efforts is to adopt automated-based testing that reduces the burden to the business. However, the true secret to this approach’s success is for health plans to recognize what is working within the current landscape and to persist forward into the future with a new, more successful version of the current enterprise.

Problems with this approach occurred with extremely adamant organizations that did not want to repurpose any part of the prior ecosystem, even if it worked well. With the “keep nothing” mindset, these projects often did not even get off the ground.

The plans that were successful with the MVP approach were willing to build their new business around a viable subset of the existing technology stack, identifying critical aspects like provider data sources and other key components of the ecosystem that provided a solid foundation to accelerate this effort. Looking back, this strategy enabled the health plans’ very aggressive timelines. This strategy also allowed them to focus on what was truly important, the member experience.

Health plans will always look for opportunities to break barriers into new markets both in the commercial and government areas. The MVP member-centric approach can serve as a way for health plans to reinvent themselves, differentiate their offerings, and break barriers into new markets to compete for the future.

 

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.