Executive Discussion: Preparing for the Future of Care Management with an Integrated Operating Model
Part 1 of a 2-part series, where HealthEdge® Vice President of Product Development Bobby Sherwood discusses how a new operating model can transform care operations for health plans.
In this installment, we cover:
- What is an ecosystem operating model?
- Addressing workforce shortages with AI
- Redesigning care delivery to improve outcomes
In part 2, Sherwood shares more about measuring success with AI-powered tools, steps to achieving operational transformation, and seamless data sharing.
Nobody goes to nursing school to push paper.
What if care managers could reclaim time currently lost to authorization reviews and compliance chases? Imagine redirecting those hours from administration and back to what really matters: engaging members, improving outcomes, and transforming care through meaningful relationships.
That’s the fundamental shift happening in healthcare now. Health plans are under unprecedented pressure from rising medical costs, regulatory demands, and workforce shortages. And the traditional approach—like layering on additional software and hiring more staff—isn’t sustainable. Something has to change.
At HealthEdge®, we’re delivering a different approach: an ecosystem operating model. We combine next-generation, AI-enabled technology with services designed to lower total costs—and we build contractual accountability into the model.
We sat down with Bobby Sherwood, Vice President of Product Development, to explore how this operating model goes beyond traditional software, and why measurable outcomes are raising the bar.
Defining the New Standard: What is an Ecosystem Operating Model?
How do you define an ecosystem operating model? And how is it different from traditional business process outsourcing?
Traditional business process outsourcing is essentially labor cost arbitrage—taking existing processes and doing them cheaper, often through offshoring or team scaling. You’re doing the same work, just with different people.
Our ecosystem operating model is fundamentally different. We’re reimagining the entire process through technology to deliver transformational outcomes, not just cost savings. It’s about operational transformation, not just labor efficiency.
Here’s what makes our approach unique: we combine HealthEdge’s integrated solution suite with clinical expertise and AI-driven automation. But most importantly, we take accountability for actual care outcomes. We’re not just providing technology. We’re building toward taking responsibility for moving the needle on medical cost trends, member satisfaction, and clinical quality measures.
That accountability changes everything. We succeed only if you succeed. The partnership dynamic is completely different from a traditional vendor relationship.
Supporting a Strategic Shift for Health Plans
HealthEdge is already delivering and optimizing an ecosystem operating model for health plan customers. What does that shift really mean for health plans, and why is now the right moment?
This evolution gives health plans unprecedented flexibility and choice within a full-stack, integrated ecosystem. Health plans can leverage delivery options to focus on which business metrics matter most for their specific strategies and do more with existing capabilities and resources.
Now is the right moment because the traditional vendor model has created fundamentally misaligned incentives. Historically, health plans license software through contracts that aren’t directly tied to member outcomes or total cost performance. While these tools can enable improvement, the commercial model itself isn’t structured around shared accountability for results.
Our ecosystem operating model reshapes legacy systems, and HealthEdge moves beyond vendor status to become a performance-aligned partner. This means our success is directly tied to delivering the specific clinical and financial outcomes that matter to each health plan. We’re accountable for results, not just software uptime. And frankly, the market is ready for this. Health plans are facing a perfect storm of pressures that’s making them more open to different arrangements.
Addressing Workforce Shortages with AI
Speaking of those pressures—rising medical costs, regulatory demands, workforce shortages—which one is forcing the biggest operational change right now?
If I had to pick one, it’s workforce shortages. Health plans can’t hire clinical staff fast enough to keep pace with member growth, stringent regulatory requirements, and the increasing complexity of care management.
This shortage is driving urgent interest in our approach. When you can’t solve the operational bottleneck by adding more people, you have to fundamentally reimagine how work gets done.
This is where AI technology within HealthEdge GuidingCare® becomes exceptionally powerful. Our system empowers health plans to address staffing shortages by automating routine tasks and enhancing clinical efficiency. Features like Automated Clinical Summaries and Intelligent Document Processing reduce administrative burdens, while Intelligent Care Guidance and Ambient Intelligence streamline decision-making and ensure documentation completeness. This allows health plans to redeploy clinical resources to high-impact activities like complex case management and member relationship building, improving care outcomes and operational efficiency.
Think about authorizations. Most nurses did not go into the profession to review paperwork. But authorizations take up so much time and budget because of the compliance burden. If we can demonstrate at scale that we’ll handle all of it, keep health plans compliant, guarantee the savings, and deliver the outcomes health plans need, nurses will gladly hand-off that work. Then health plans can shift those nurses to activities that truly impact the cost curve.
Redesigning Delivery for Measurable Impact
Historically, care management technology has focused on tools and workflows. How is HealthEdge’s Care Solutions approach different in terms of the outcomes it’s designed to deliver?
Traditional care management technology asks, “How can we make existing processes more efficient?” We ask, “What outcomes does the health plan need to achieve, and how do we redesign the entire care delivery model to get there?”
In traditional software models, vendors provide powerful tools that enable improvement, but responsibility for realizing the full value often rests primarily with the health plan. While renewals can reflect satisfaction over time, the commercial structure itself is typically based on access to technology rather than shared accountability for measurable outcomes.
When financial accountability is tied directly to outcomes, the dynamic changes entirely. You’re not just another vendor in their stack of dozens or hundreds of vendors. You become a true strategic partner, fully invested in your clients’ success, with mutually aligned incentives and shared accountability for real, measurable outcomes. This fundamentally transforms the engagement from a transactional relationship into a collaborative alliance built on trust, transparency, and joint achievement.
Our integrated platform doesn’t just digitize existing workflows. It reimagines them entirely. Instead of managing care through disconnected systems and manual processes, our platform enables seamless orchestration of member engagement, clinical interventions, and administrative processes. The result is measurable improvements in clinical quality, member experience, and cost management that we contractually guarantee.
Ready to learn more about reaching and engaging members, measuring the ROI of an ecosystem operating model, and how to get started?
Read part 2 of the blog here: Adopting an Ecosystem Operating Model and Measuring ROI.
About Bobby Sherwood
Bobby Sherwood is VP of Product Development at HealthEdge, where he leads strategic direction for the company’s cloud-based care management solutions and Business Process as a Service offerings. With deep expertise in healthcare technology and payer operations, Bobby works with health plans to transform care delivery models and drive measurable outcomes.
