For decades, health plan CIOs have been increasingly pressured by their business partners to find cost-effective ways to support the transformation of healthcare administration. There are many examples of this including:
- The development of distinct customer market segments, which have driven a need to deliver an increasing variety of product and service offerings
- Patient-centered care models, which have driven the need to develop new reimbursement models and care coordination/ utilization management capabilities
- The introduction of subsidized premium in the purchase of individual policies, which requires entirely new and complex billing and collections processes
In response, IT departments across the country aligned projects to deliver capabilities needed to support each of these strategies separately, enabling health plans to create distinct market-facings personas on an aging base of legacy applications. Today, it is not uncommon to have multiple systems to accomplish core functions of a health plan. Each must be maintained, compliant, high-performing and consistent with overall business policies as well as seamlessly serving distinct market segments.
With health reform, market drivers are now pushing for a foundational convergence of segments. The rise of consumerism is consistent across market segments. Technology to support consumerism must span the enterprise. Compliance has become a consistent and rising driver of capabilities and must be consistently implemented across market segments. The temporary efficiencies once gained from disparate systems now pale in comparison to the inevitable cost of remaining compliant and consistent, which can be more effectively achieved with a unified platform.
In this reform era, leading health plans are examining fundamental aspects of their businesses that include looking to create a new model for context-driven capability, differentiation and innovation based on common core processing. They seek an IT strategy to execution paradigm that creates a new platform for growth supported by transformational systems providing both transaction processing combined with an actionable information platform. They want a platform that enables the organizations to respond with real-time predictive and adaptive analytics to the information contained in transactions without the overhead of legacy data warehouse-based analytics engines. In a December 2013 article in HBR titled, “You May Not Need Big Data After All”, the authors studied organizations that made investments in Big Data Analytics and still found that critical market-leading decisions required real-time, evidence-based decision making at the most granular level. The authors say those who do this will drive innovation in the market, and a cultural shift in the context of information and analytics. They cite four critical practices: “They establish one undisputed source of performance data; they give decision makers at all levels near-real-time feedback; they consciously articulate their business rules and regularly update them in response to facts; and they provide high-quality coaching to employees who make decisions on a regular basis.”
New core administrative systems must deliver to this tall order with consistent models that enable delivery of the consumerism agenda and drive quality outcomes necessary for reducing overall medical costs. The actionable information platform allows health plans to leverage all customer-related interaction data to drive pro-active interactions with their customers. An actionable information platform creates opportunities to leverage traditional population health and historical analytics with emerging analytics derived from new sources of data like social media interactions. The result can be astonishing – actionable information allows health plans to respond to the needs of their customers and create efficient and compelling products. Monitoring those products for compliance is “built-in” to these platforms. New core systems that contain both transparent transaction processing and actionable information platforms will need context-driven business rules engines, reducing redundancy of IT development and maintenance and reducing overall time to value. Employees of plans utilizing these new systems will be more effective in managing to company policies, reduced training time, and ability to leverage the modern interfaces of their personal devices and gain confidence that their interactions with constituents provide clear, concise, and correct information.
For decades healthcare organizations have deferred major transformations of their IT platforms as business models evolved. Revolution is the operative word in healthcare today. It is time to transform Health IT. Market drivers are calling for simplified administration and personalized engagement. We’ve grown used to refreshing our personal technology platforms every two years as new consumer electronics hit the market. Don’t our employees and customers deserve the same kind of refresh?
The Healthcare Compliance Imperative
March 25, 2014, 1PM - 2PM EDT