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Achieving True Digital Transformation for Healthcare Payers

healthcare digital transformation | healthedge

Healthcare Payers: True Digital Transformation

Healthcare organizations and leaders are thinking about how to provide the experiences that patients and consumers have come to expect from the healthcare system. However, the legacy technology platforms that many organizations have today–especially payers– often disrupt digital transformation.

In a recent episode of The Healthcare Solutions Project podcast, Sagnik Battacharya, EVP at HealthEdge, talks about how payers can accomplish true business transformation, both in terms of data capabilities and interoperability, and the reasons why they should.

Incentives to Drive Interoperability

Provider-to-provider interoperability has taken significant strides forward in the last decade, but interoperability between payers and between payers and providers isn’t yet at the same level. EHR vendors have done a good job of integrating disparate systems, showing that there is a real opportunity for tighter integration and interoperability between existing payer systems.

Incentives and rules being put in place by the government, such as the 21st Century Cures Act, are now being implemented through various rules published by CMS and are driving a focus on interoperability, especially for payers.

The key to interoperability goes beyond having the correct tools, such as APIs, FIHR, and CCDs. These capabilities don’t matter if the information is not available to the right person when and where they need it and in a format that is easily digestible. Oftentimes, providers are getting too much information to sort through in the limited time that they have. When interoperability is executed correctly, the technical capabilities seemingly fade into the background and the result is patients and providers have the information they need at their fingertips.

Digital Transformation Requires Both Technology and Mindset

Businesses run on technology – but that technology is not always created equal. Businesses need to ask themselves if the platforms and technology they are using are allowing them to move their business at the pace that they want. While every business transformation takes time, if technology is your rate-limiting step, then you would be hard-pressed to call yourself a digital business.

But digital transformation requires more than just having the appropriate technology infrastructure. Sagnik Battacharaya emphasizes that it requires “a mindset that allows an organization to move at the pace of consumer expectations over the next ten years,” and points to digital companies like Amazon, Apple and Google as examples of companies that healthcare businesses can learn from.

These digital companies are incredibly end-user-focused. They have a high degree of quality and incredibly high service levels, but providing amazing member experiences is not enough. If you want to be truly digital, you also need to be agile enough to know what consumers are going to expect 10 years from now.

What’s Driving Businesses Toward a Digital Transformation?

The areas of growth within the health insurance markets today are centered around Medicare Advantage, Medicaid and healthcare exchanges. Compared to employer-provided plans, individuals have more choices available to them when selecting one of these options. Numerous plans could be competing for their attention through services or the experiences they provide resulting in individuals who are selecting plans not only based on the premiums but on the services and digital experiences they desire.

Benefits of Digital Transformation

According to a recent survey of HealthEdge customer executives, their highest strategic priority over the next couple of years is operation efficiency. They want to take better care of their members, and one way they can do this is by increasing efficiency – resulting in less spending. These savings can then be passed onto their members.

Weaknesses within legacy systems include the inability to be agile and make business transformations faster and easier. Sagnik discusses how customers leveraging digital technology from HealthEdge during the Covid outbreak were able to very rapidly make changes to comply with the new rules that CMS was pushing out. He states “because we had built this really configurable system that put control in the hands of the business users and the clinical users, they were able to make those changes in less than a week…”

A digital transformation could help an organization improve other key business metrics as well. Member loyalty and retention is increasingly important as individuals are given more choices. According to Sagnik, one member health plan has seen 99% member retention because they have successfully engaged with their members digitally.

Another metric closely monitored by health plans are auto adjudication rates. HealthEdge regularly sees their clients who are able to attain over 90% auto adjudication rates, which would be pretty difficult to accomplish with legacy systems.

Learn more about becoming a digital payer here.