Healthcare Reform – Disruptive Times Demand Disruptive Technology

With healthcare reform becoming the law of the land, the need for a new kind of agile technology is now greater than ever – for all healthcare organizations.  Though details are not yet final, the far-reaching legislation is frankly a seismic shift across the industry that requires healthcare organizations to move far beyond “business as usual”. 

 Payers, physicians, hospitals, prescription benefit managers and life science organizations alike face certain new realities, including: 

  • Increased regulatory oversight – A proliferation of rules, brutally short ramp-up periods, more reports and more corrective actions are inevitable.
  • Tighter profit margins – This results from mandated medical loss ratios, new taxes and potential fines.
  • Heightened competition – Regulation leads to greater commoditization of products and creates a larger pool of individual consumers.
  • Massive swells in transactional volume – A sharp increase in calls, claims, bills, visits, authorizations, appointments, etc., was coming anyway due to the aging of the population. Now, tens of millions of additional consumers are slated to be added to the system.
  • Personalized service – with a mandate to now enroll uninsured individuals, organizations are going to need to be able to specialize their client interactions much more than ever before. More calls, more questions, more opportunities to acquire – or lose -- members.

Pegasystems has enabled companies to capitalize on healthcare reform for several years.  In fact, we helped Massachusetts’ state-mandated, reform-related customer acquisition and enrollment activities for Blue Cross Blue Shield of Massachusetts (BCBS MA).  In 2006, when Massachusetts state law went into effect requiring all payers to extend coverage options to individual residents, BCBS Massachusetts was able to respond quickly and adroitly, deploying SmartBPM in less than 17 weeks despite ongoing regulatory changes and untimely clarifications.  The individual market was a new frontier for the organization, but it was able to get to market faster and better than the competition. Our advanced SmartBPM technology streamlined the sales experience, generating automatic quotes and managing all on-boarding activities.  Ultimately, BCBS Massachusetts captured almost 80% of the new market. Reform, by its very definition, is disruptive, and disruptive times demand disruptive technology.   To successfully leapfrog to next-generation healthcare, organizations need to take advantage of new opportunities and thrive, not just survive. They need new, unprecedented efficiency, agility and speed if we are to achieve the ultimate goal of a healthcare system that works for all of us.