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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 Outdated technology and siloed systems can adversely impact operational efficiency, create significant processing challenges, drain productivity, and ultimately impact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.

Ever have the kind of day where you wish you could go back and start over? Press reset so you could avoid the errors you made the first time around? Unfortunately, that is impossible, yet thinking about it can provide some insights out how to move forward and make changes in the real world.

Take the healthcare industry, for example. What would a do-over look like if we had the opportunity to go back in time and make different choices? If one could wipe the current slate clean, how could we build a better, more productive, and efficient healthcare system?

Fee-for-service reimbursement is one stand-out do-over opportunity. People took each step thinking it was the right thing to do. Interventions designed to solve one problem layered on top of other interventions designed to solve other problems, without consideration on how they would impact the system as a whole.

Fee-for-service reimbursement models have resulted in several developments that merit a do-over:

• “Sick-care” rather than Healthcare- The incentives associated with fee-for-service reimbursement caused our system to ignore people until they were “patients.” No symptoms, no illness, no service. The culture focused on treatment to the near exclusion of prevention.
• Another artifact of fee-for-service, healthcare delivery fractured into specialized components between which there was little, if any, communication. Higher reimbursements for specialty services meant each patient engagement generated revenue. Each specialist treated their patient in a silo. The problem is that patients aren’t silos.
• Treating disease, or proactively preventing it, is more of a science. The data proving benefit of treatment fidelity and lack of variation is there. For years, the concept of evidence-based medicine was eschewed by many providers.
• The development and proliferation of IT systems that can’t communicate with each other.
• The advent of an adversarial culture between providers and payers rather than one based on cooperation and collaboration.
• The creation of a system that makes it all but impossible for consumers to identify and compare the cost and/or quality of services provided.
• Zero incentive for providers to proactively engage with patients around chronic disease treatment and/or management.

Sometimes it seems going back in time is the only way to fix a problem that’s been generations in the making. On the bright side, the advent of outcomes-based reimbursement and value-based models has started to shift this dynamic. Collectively, we are moving towards an improved system based on quality, outcomes, and shared risks.

Whether it is value-based benefits, episodes of care, or evolving state and federal regulations—without the right technology, health plans will struggle to keep up with trends and changes in the industry. These challenges only intensify for smaller health plans with limited resources and less margin for error.

To remain competitive in today’s market, health plans must have the ability to stand up new lines of business and benefit plans quickly and efficiently.

For many payers, bringing a new product or benefit to market often requires significant time and resources. For health plans using older core administration systems, configuring a new benefit plan involves the claims department working with the IT department to explain the benefits and what’s covered, conduct testing, identify errors, and find solutions.

This back-and-forth process, which can take months to complete, occurs while members are already utilizing the benefits. Health plans are pressured to get payments out of the door, accurately and efficiently. Still, they cannot process claims against a benefit that is not yet configured in their system, resulting in processing claims incorrectly until the benefit is placed into production.

Health plans must then handle the backlog of incorrect claims. This workload requires IT and claims resources to run a report with hours spent working to identify what was impacted by this benefit plan and running backouts and re-processing the claims to get everything in sync.

With so many steps and so much ground to cover, this cumbersome process often causes IT departments to become bloated. The IT resources are highly-skilled and know the technology well, but they do not necessarily know the business or understand the benefits, leading to more potential errors and inefficiencies.

With the immense time and resources spent on deploying one benefit plan, how can health plans react to shifting consumer behaviors and the evolving healthcare landscape and quickly go-to-market? Health plans need a flexible system that allows them to test and implement those benefit designs in a timely manner so they can focus on making continuous improvements that attract and retain their members and drive success in their business.

Gone are the days of the traditional, slow, steady insurance business. Welcome the next generation of health insurance, where plans must be fast and agile to please their members.

Today, health plan consumers are empowered, informed and demand more sophisticated, convenient, transparent, affordable, accountable, and personalized service.

Health plans must shift their business models to embrace empowered consumers by consistently offering the best, most competitive services, and benefits.

This approach requires payers to invest technology that supports the introduction of new services and products and do so at the consumer’s speed, in a manner that meets the consumer’s needs.

Does your system make it difficult for you to create a new plan or benefit change? Sometimes it can take six to nine months to complete these updates in the system in time for enrollment. Do these changes require highly-skilled IT professionals? Oftentimes, these changes can take resources and hours away from other valuable projects for an organization. And even then, with all of this time and effort, it’s not guaranteed that it will be successful.

For today’s consumer, and tomorrow’s success, health plans need technology that enables them to make changes to plans and benefits in a matter of hours. This capability pleases members and providers alike by providing access to accurate information in a timely manner.

Does your system allow users to see information in real-time? Baby Boomers, Gen Xers, and Millenials are demanding transparency and access to accurate real-time information available to them 24/7 through a variety of channels.  This means layering the digital information era on top of the traditional health insurance infrastructure in a way that allows your organization to quickly respond to market demand and be the first to offer the most up-to-date, innovative plans.

Health plans that implemented a core administration system twenty years ago and have only taken technical upgrades for two decades struggle to efficiently operate in today’s market. The failure to design their processes around flexibility to adopt the enhancements delivered to them over the years puts health plans at a competitive disadvantage.

And while the system may look better today, it’s not performing any differently than it did in the ’90s. Furthermore, the health plan is not getting any value from the additional code they are paying for in their maintenance and licensing agreements.

CTOs and CIOs in this situation must ask themselves:

–         Why is your organization operating the same way as you did 20 years ago?

–         Why aren’t you taking advantage of any new enhancements?

The typical answer is that the time and cost associated with implementing the enhancement and learning how to use the new solution are too high.  Change is expensive unless we build a culture of continual optimization.

At some point, if payers simply let business users run the core administration system without focusing on the outcome of why they execute a certain process, it will result in “paving the cow path” and they ultimately just achieve inefficiency faster in a better-looking system.

Enhancements and upgrades add value, give health plans a competitive advantage, and allow organizations to operate more cost-effectively. Health plans must have the ability to adopt enhancements, have confidence they will work, and the flexibility to build on those functions and align their strategy to the Product Roadmap.

It comes down to whether a health plan has the culture that will continually take enhancements and not find themselves painted into that box twenty years later, wondering how they let so much time slip by.

I’ve seen this happen to numerous organizations, and I wonder what led them down this road? A health plan can look at a timeline of all the different versions of enhancements and upgrades that they ignored and correlate these milestones with potential opportunities they missed that could have advanced their business. Even though they had all the tools, answers, training, and resources at their fingertips, they just were not open to changing what they already knew and updating the way they operate.

For health plans that fear change, my advice is to embrace the upgrades that feed into continual optimization processes and allow your organization to make progress in the future.

For health plans, operational efficiency could be the first step in their approach to innovation. While it may not be the most exciting aspect of the business, achieving operational efficiency will enable them to remain competitive in the long-term.

A health plan can have the most innovative ideas in the world, but without the resources to back it up, they most likely will not get very far. Operational efficiency, automation, and accuracy free an organization to focus on innovation. By prioritizing operational efficiency, organizations can redeploy the time and resources typically spent on routine  administrative tasks, and shift to transformative projects.

Flexibility and agility are also incredibly important. A health plan with great ideas for new market-competitive products that advance the organization’s innovation goals requires the technology flexibility to configure and automate them, along with the ability to make changes quickly. Otherwise, they will end up losing momentum and missing out on crucial business opportunities.

Health plan innovation touches many aspects of the organization, including member engagement, payer-provider collaboration, and business processes, and in many cases, impacts benefit designs, provider contract designs, and other aspects that help drive behavior. To remain competitive, health plans must have the freedom to test new ideas, try modeling, make mistakes, and access their data in real-time to see what works and continue improving.

When it comes to implementing innovative ideas, a core administration system that breaks down product design barriers, increases efficiency, and delivers real-time transparency is a necessity. If the majority of an organization’s ecosystem is cutting-edge, but the core administration platform is outdated, everything else will fall behind. Healthcare moves fast, and health plans need the ability to be forward-thinking.

All of the health plans I talk to have incredibly innovative ideas. They want to invest in a meaningful member experience, they want to enhance payer-provider collaboration, and they want to transform their organizations. To achieve these goals, they need a system that empowers them to focus their skills, experience, and capabilities on actively impacting the true health of their individual members and the U.S. healthcare system as a whole.