With many components of the Patient Protection and Affordable Care Act already implemented, health plans are taking additional steps to further reduce their cost structures, improve efficiencies and excel in the evolving healthcare landscape. Certain, specific technology-enabled solutions can help healthcare payer organizations meet these goals.
Integrate Enterprise Systems to Drive Administrative Efficiency and Reduce Costs
The best core enterprise systems automate the benefits administration of payer organizations – member enrollment, premium billing, claims administration, customer service and other functions. The leading care management applications streamline and improve the delivery of member care, specifically case management, disease management and utilization management.
Separately, core and care management platforms can dramatically improve productivity, mitigate risk and reduce health plans’ costs. When integrated, these systems provide payers with an opportunity to support more efficient care models and launch value-based products that engage members in health improvement. By integrating enterprise systems, health plans can more efficiently manage health programs in new member-centric settings such as patient-centered medical homes and accountable care organizations.
Some payers are further integrating core and care management systems with applications that automate administrative tasks and reduce manual configurations associated with network management. These applications improve contract modeling and price-variation discovery and help avoid the costs of manual intervention further downstream.
Ideally, healthcare payers integrate all of these systems with constituent web-based applications that automate transaction processing and information exchange with external constituents, thereby enhancing the coordination of benefits and care delivery. Such web applications can markedly improve health plans’ interaction with consumers, providers, employers and brokers.
Leverage Outsourcing
Business management services present an additional, highly effective opportunity to improve on the gains of integrated, efficient enterprise systems. Medical-loss ratio rules require that at least 80 cents of every premium dollar be spent on direct patient care, and outsourcing can help minimize the amount that payers spend on administration.
The pressure to increase administrative efficiency has increased demand for business management services. According to recent industry reports, 40 percent of payers plan to increase outsourcing of business processes to drive down costs. A qualified, industry-experienced outsourcing partner can reduce unnecessary expenses and provide flexible, on-demand access to specialized resources and consultants. Cost-effective offshore, onshore and hybrid models can help lower the cost of many administrative functions, including front end-services such as imaging, OCR/scanning, enrollment and claims processing.
Application management services, too, can help health plans drive further administrative cost savings. An expert, payer-experienced vendor can manage and host a health plan’s applications, whether its systems reside onsite or at the vendor’s data center. And the benefits can go well beyond lower, more predictable costs. Application management services can accelerate implementations, speed the resolution of software issues, and improve software performance and reliability.
Regardless of how healthcare reform evolves, payers will gain competitive advantage by further streamlining administrative processes, integrating enterprise systems, and fully exploring application management and business management services.
Dan Spirek is the Chief Strategy and Marketing Officer, Executive Vice President, Enterprise Strategy and Communications at TriZetto. As a founder of TriZetto, Spirek has been a major driver of the company's enterprise-wide vision and capability development. As chief strategy and marketing officer, Spirek is accountable for driving enterprise strategy development, enablement and execution as well as enterprise-wide marketing and communications. Prior to TriZetto, Spirek held executive information technology roles with PacifiCare Health Systems, FHP International Corp., and TakeCare, Inc.
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Edited by
Jennifer Russell
