Executive Discussion: Adopting an Ecosystem Operating Model and Measuring ROI 

Part 2 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 the first installment, Sherwood defined what an ecosystem operating model is, and how it can enable payers to improve care delivery, streamline administrative processes, and improve member outcomes.

Read part one here: Preparing for the Future of Care Management with an Integrated Operating Model.

Continue reading to learn more about measuring success with AI-powered tools, steps to achieving operational transformation, and seamless data sharing.

Investing in Member Engagement and Access

Health plans need to reach and engage members to drive outcomes. Where is HealthEdge investing to make that happen?

One thing that is absolutely critical to driving outcomes is activating your member population. If health plans can’t move the needle on how members are progressing through their health journey, the plan is going to struggle to demonstrate meaningful impact.

We’re significantly expanding our HealthEdge Wellframe™ solution, moving it beyond purely an app experience to include web, text-based, and email-based engagement, which is what members have come to expect in today’s digital age. We’re opening more front doors, more channels for members to come in and engage with their care team and become active participants in their own care plan.

Beyond that, we’re also focused on helping our customers and their clinical teams do more with their existing resources by targeting specific, high-impact use cases. In care management, we’ve taken a build-and-partner approach—developing features that drive operational efficiency while also forming strategic partnerships that extend capabilities. For care management, we view artificial intelligence (AI) as an augmenter and enhancer, empowering teams to work smarter rather than replacing their expertise. But there’s still opportunity for AI to take on tasks and work fairly autonomously while still keeping a clinician in the loop.

Annual health assessment completion is a prime example of how AI-powered solutions can securely and transparently enhance member outreach at scale. Today, advanced AI tools can conduct telephonic conversations with members, always making clear that the interaction is assisted by AI, and ensuring privacy and data security remain paramount. This approach not only increases efficiency and reach but also builds member trust by keeping interactions transparent while enabling health plans to engage large populations effectively—far beyond what traditional person-based methods allow.

Ultimately, the effectiveness of these investments hinges on our ability to help health plans engage more members in meaningful ways. Expanding our reach is crucial; without it, achieving measurable improvements in outcomes remains out of reach for both our clients and those they serve.

Measuring Success: Just Start

Health plans are also under intense pressure to prove ROI. How should leaders think about measuring success when adopting Care Solutions within an ecosystem operating model?

My answer is simple: just get started.

Evaluate a use case you’re already familiar with. Work with a partner that brings strong technology, services, and a skilled, comprehensive team to the table. Let them demonstrate how they can deliver better results than your current approach.

Define what “better” looks like for your organization—it could mean higher engagement on your portal, more completed assessments, closing more care gaps, or any of the performance metrics health plans typically track, such as NCQA, HEDIS, or STAR ratings. Focus on one area and work with a partner to deliver measurable value. Once you see proven results, you can expand the program with confidence.

Success measurements should be tailored to what matters most to each health plan’s business strategy. The key advantage of our integrated ecosystem operating model is our ability to contractually guarantee outcomes, because we have control over the entire technology stack and operational process—not just isolated components.

The Future Operating Model

If we’re having this conversation three years from now, what will the most successful health plans be doing differently as a result of embracing an integrated ecosystem operating model?

We’re looking at a complete shift in how health plans operate. The traditional model relies on additional staff or incremental efficiencies—which doesn’t allow for true transformation. In the future, our integrated ecosystem operating model reduces the administrative operating burden, adds expertise and allows health plan staff to focus on high-value work.

Over time, payers continue to see improved outcomes and cost reductions and gain the ability to focus on bigger strategic goals. Partnering with organizations that track and deliver measurable outcome metrics frees up their time, budget, and headspace. They are able to really focus on how they want to compete, how they want to differentiate, and how they want to win. They can leverage resources and talent on their unique strategic priorities, whether that’s specific member populations, clinical specialties, or market differentiation.

The most successful health plans will have a fundamentally different operating model. These health plans will deploy resources toward activities that move the needle on their strategic objectives, rather than getting bogged down by operational tasks that can be performed more efficiently through specialized partners and advanced technology.

And I want to emphasize—this isn’t about eliminating jobs, downsizing or taking away opportunities. This is about removing the work people find most tedious and giving nurses and care managers their passion back for why they got into this profession in the first place.

Steps to Operational Transformation

For plans just starting this journey, what’s the best first step toward moving from point solutions to a true integrated ecosystem operating model?

Our Advisory Services team works with health plans to deliver a total cost of ownership assessment and to determine their cost drivers and areas for improvement. This exercise helps health plans consider a specific line of business use case as a starting point to demonstrate clear ROI and realize immediate administrative efficiencies.

Post-discharge follow-up, member enrollment, or assessment completion are great examples because the intervention-to-outcome relationship is well established and measurable.

Once you prove the value of the model with one line of business, expansion becomes much easier to justify and implement.

Leverage Seamless Data Sharing & Transparency with GuidingCare

What else do you want health plan leaders to know about this transformation?

First, interoperability and seamless data sharing set us apart in the industry. Our entire GuidingCare platform suite shares a unified data model and API framework enabling direct, real-time integration with health plan systems. Unlike solutions that rely on piecemeal acquisitions or fragile partnerships, HealthEdge delivers true interoperability out of the box. We can work directly in systems as the direct source of truth, with direct documentation and all the automations and intelligence built in. That greatly simplifies how these interactions and services are delivered.

Second, embracing an ecosystem operating model is not just an operational shift—it’s a true business model innovation. Health plans that adopt this approach are positioning themselves for sustained success in an increasingly competitive market and evolving contracting frameworks. By moving beyond traditional software acquisitions, health plans equip themselves with a differentiated, future-oriented model that accelerates sustainable growth and delivers long-term value.

Future-Proofing Health Plan Operations with AI-Powered Solutions

The market is changing rapidly. Existing cost and regulatory pressures aren’t going away, and new challenges emerge every day. The question for health plan leaders is whether they want to keep doing things the way they’ve always been done, or whether they’re ready to move beyond the familiar and proactively shape the future of their organization’s success.

Learn more about how your health plan can leverage AI-powered tools to enable strategic, scalable, and intelligent automation. Read the data sheet, Transforming Utilization Management with an AI-Powered Decision Intelligence Ecosystem.

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.