The importance of transparency in the new healthcare marketplace

By | HCEG Top 10, Costs & Transparency

Transparency in healthcare has been an important topic for many years. The usual focus of discussions in this area had been on providing the right information to leaders inside of the organization, to enable them to make good decisions about their businesses based upon the performance of various products, offerings and services teams. Being able to see these metrics in real-time, in a way that would enable these leaders to pivot or shift as market needs changed, was considered the key to any transparency initiatives. Over the past few years, the expectations related to organizational transparency have expanded significantly, particularly related to external transparency. This has been driven by a number of important factors, most significantly the shift away from traditional fee-for-service business models towards models that leverage new approaches including value-based benefits and value-based payments (also still sometimes call pay-for-performance).

While internal transparency is still critical for business success, many health insurers are now realizing that external transparency is equally important. This is particularly true with regards to many of the new healthcare business models, and particularly those models that require the active participation of stakeholders like members and providers. The success of many of these new models will be gated by the health plans. ability to provide accurate, actionable, real-time information to everyone involved in the healthcare delivery cycle. Members must have the information required to enable them to quickly and accurately evaluate price, quality and service, and to comply with their recommended care plans.

At the same time, providers must have the ability to get the real-time information that will be required for them to play their roles in the new healthcare ecosystem, particularly related to their care of at-risk groups who may be participating in new programs where the providers are rewarded for their ability to help drive a healthier and happier population. To be successful in this new marketplace, health plan executives must determine what will be required to fully participate in this evolving healthcare economy, and they must then build and then execute a plan to bring their organizations to the required levels of transparency in terms of their people, their business processes, and, most importantly, their technology.

By Ray Desrochers, Executive Vice President, HealthEdge

Payer Provider Integration and the Eight Questions You Should Be Asking Yourself

By | Interoperability / Consumer Data access, HCEG Top 10

CMS Leading the Way

As we continue to look for ways to drive improvements in quality of care while positively impacting the rising cost trend, collaboration between and the integration of payer and provider organizations has emerged as a leading strategy and a vision for the future. While we see evidence of a more integrated future across all healthcare sectors, today CMS drives changes through the Innovation Center founded under the purview ACA.

The most prominent example of innovative initiatives is the ACO Pioneer Program implemented by CMS. The overall intent is to create accountability for the care of a population (Population Health) and align incentives with the providers and payers responsible for these populations. Initial models focused on shared risk and upside for savings while protecting against downside risk and then moving towards full risk agreements in the future. CMS continues to demonstrate innovative thinking through the introduction of new reimbursement models, for example bundled payments for specific services. Again, aligning incentives between payer and provider and promoting care coordination will ensure that patients experiences the full benefits of the Triple Aim of healthcare: focusing on population health, improving the experience of care and impacting the per capita cost of care..

How these initiatives are implemented varies across regions, but all are focused on the same core elements: defining the needs of the population, designing interventions to address these needs, coordinating care across care modalities, aligning incentives across the ecosystem and measuring performance. As I stated, companies implementation approaches vary, for instance what role does the health plan care manager take Who provides or funds the required care coordinators

As CMS clearly understands, the key to driving improvements in quality is a new system for provider reimbursement. Specific programs are being develop and tested to move away from payment for service to payment for value. A recent key initiative driven by the CMS Innovation Center is their Bundled Payments for Care Improvements (BPCI). CMS has created four broad models of care which link payments for multiple services beneficiaries receive during an episode of care. These models test different reimbursement approaches graduating to a full risk based prospective payment for all services. In Model 4, participating organizations enter into agreements where they are accountable from a financial and performance perspective for an episode of care. The accountability keeps the focus on driving improvements in quality and a reduced cost for Medicare.

Another recent focus area being led by CMS is the Comprehensive Primary Care Initiative (CPC) launched in late 2012. The CPC is a five year plan focused on improving patient care by helping primary care practices improve their operations and work with patients to provide:

  • Access to care providers and Continuity
  • Planned Care for Chronic Conditions and Preventive Care
  • Risk-Stratified Care Management
  • Patients and Caregiver Engagement
  • Coordination of Care Across the Medical Neighborhood

In an April 2016 announcement, CMS released the largest-ever initiative to improve how primary care is delivered and paid for in the United States. The Comprehensive Primary Care + (CPC+) will have two tracks:

  • Track 1 practice get a monthly care management fee in addition to fee for service
  • Track 2 provides the practices a monthly care management fee, reduced fees for E & M services but a monthly up-front comprehensive primary care payment for these services.

Lastly the newly announced Medicare Access and CHIP Reauthorization Act of 2016 (MACRA) directly impacts provider reimbursements and specifically incentives compensation for quality of care. The program focuses on changing the existing Sustainable Growth Rate (SGR) payment formula. MACRA should create a new framework for rewarding providers for giving better, rather than just more care and combining existing quality reporting programs into a single program. It also moves away from rewarding providers for use of technology under the current Meaningful Use Program and into rewarding providers who use technology to demonstrate improved care and outcomes.

While CMS is seen as leading the way, we have seen examples of commercial payers implementing their own value-based payment programs. Horizon Blues Cross and Blue Shield of New Jersey successfully implemented bundied payment programs that focus on payments for episodes of care as evidenced by their recent press release on February 16th, 2016. Aetna, Anthem and United Health Group all have plans underway to shift the majority of their payments to value based contracts over the next few years. While these programs have been in existence for years, what is different is the processes and technologies that support these programs that allow them to be successful.

Technology Implications

Technology is critical to the success of payer-provider collaboration and integration initiatives. CMS understood this and through the ACA has invested millions of dollars into helping providers acquire systems to support the creation of environments that allow data to be available and interoperable across organizational boundaries. Data is key to the success of all of these new collaboration and integration opportunities. Organizations that are self-contained, such as Kaiser, have an easier path to creating an environment where data is defined singularly and available across the organization. Because many of the organization that are collaborating to manage the health of a population are separate and distinct companies, their information architecture may be different making it difficult or impossible to exchange data. While the healthcare industry, spurred on by HHS, has been focusing on establishing and implementing standards for patient data exchange, we as and industry, have not made the progress required to find lasting success. We still have work to do as do vendors that provide solutions to this market.

Organizations cannot rely on single vendor solutions but must invest in tools and resources to support data exchange and aggregation between multiple platforms. The long-term vision is for the exchange of data to be at a discrete date element layer as opposed to sending a pdf report that cannot be used to support any analytic needs. The efforts cut across company boundaries and demand the interoperability of data across the entire healthcare ecosystem to support improvements in care at the time of service, enable the use of data to improve our ability to analyze the health of the population and support the implementation of interventions designed to address specific healthcare conditions. These efforts are not for the faint of heart, nor will they be addressed in a short-time frame. We will need to have patience to address both organization and technical barriers while recognizing the need to push forward as an industry to make progress. Lastly, in addition to data exchange and data aggregation for analytics, some of our existing core systems will need to be enhanced. For example, a claims system will need to be able to support payment for episodes of care as opposed to an individual claim.

Given all of this uncertainty, how do we as organizations move forward with these business ventures What are the critical success factors that need to be addressed to help mitigate risks and improve the likelihood of success

  1. Does your organization have a clear business strategy and plan that identifies objectives, and the roles and accountabilities that organizations will provide within these new business ventures
  2. Are incentives and the allocation of funds aligned to support the objectives you have defined
  3. Have you defined a care coordination strategy based upon an assessment of the health of the population that you will serve
  4. Are business requirements defined to support the model that you have developed:
  5. Does the business model identify the underlying data/information needs for each role/organization involved in this venture including the source and use of the data
  6. Do you have knowledge of the technical capabilities of the organizations in your business model to understand to assess their ability to address the identified requirements
  7. Have you developed a resource plan to support both the implementation and ongoing operations of your business venture
  8. Have you developed Key Performance Indicators (KPI) that will allow you to measure your progress

While the above question seems overwhelming, those sitting on the sidelines may be a risk as those organizations who are choosing to play the game may creating separation and competitive advantage.


Change Healthcare

The Growth of Provider led Health Plans in the Individual Market

By | Delivery System Transformation, HCEG Top 10


Offering a health plan can give health systems a variety of strategic and economic advantages. The decision is not without risk, however. To benefit from this move, health systems will need to understand their consumers. A recent analysis provided by McKinsey & Company explains the growth of this business model and examines the key factors tied to success.

Recent Developments

Between 2010 and 2014, the largest enrollment growth for PLHPs in percentage terms occurred in the individual market. One of the primary drivers of this growth is the fact that many providers introduced public exchange plans as a way to drive volume. During that time, enrollment increased from about 270,000 to 670,000 members. This represents annual growth of approximately 25%. The number of providers offering health plans in the individual market rose to 55 from 36 during that span of time. The CO-OP shutdowns and losses incurred by large insurers, combined with heightened penalties for being uninsured, indicate that further growth in this market is likely for PLHPs.

Despite the significant increase in overall enrollment, most PLHPs remain comparatively small. In 2014, only five providers had plans that cover more than 500,000 members. In the aggregate, however, these plans had a fairly large market share. A regression analysis recently provided by Deloitte indicated that market share drives profitability for the PLHP model.

Since 2014, PLHPs have become more price competitive on the public exchanges. In the first open enrollment period (OEP), they were the price leader (the carrier offering the lowest-priced silver plan) in 15% of the counties where one or more PLHPs were available. That percentage rose to 19% in the 2015 OEP and then to 26% in 2016. PLHPs were especially likely to become price leaders in areas where CO-OPs exited the 2016 exchanges.


The possibility exists, however, that competition on the basis of price is not the appropriate strategy for PLHPs. The rise of healthcare consumerism has substantially changed what many people want from providers and health insurers. These changes play into the hands of PLHPs in many ways. If providers want to use health plans to increase volume, however, they must understand consumers price sensitivity and benefit preferences.

While people who buy health insurance for themselves tend to prefer low-cost plans, they do not base their purchasing decision on price alone. People have demonstrated a willingness to pay more for features that provide added convenience, such as guaranteed appointments, after-hours appointments, telemedicine services, and weekend appointments. The data also indicate that consumers are willing to let their health information be shared between insurers and providers.


Another important element to consider is the administrative model that these systems choose to employ. Often, the administrative infrastructure used to set up a PLHP is similar to that of a stand-alone health plan (granular claims requirements, extensive prior authorization lists, utilization management and care management prerequisites, etc.). This represents a lost opportunity for PLHPs, who really should take advantage of the chance to rethink the traditional payer administrative infrastructure. Because most provider-led plans cover 150,000 lives or less, it is impossible for them to attain the benefits of scale using the traditional payer administrative model. Greater efficiencies and reduced costs can be discovered by aligning policies between the health system and the health plans business units to achieve a level of cohesion that traditional payers simply cannot.

Health systems with their own health plans have an important advantage: integrated claims and clinical data that can allow them to produce sophisticated analytics. As a result, they should be able to make the most of opportunities for better medical management by identifying at-risk patients, offering them appropriate preventive care, and, when necessary, intervening early.

There is an opportunity for PLHPs to consider pricing and product benefits in a new way. The product benefits should be tailored to the strengths of the care management offered by the underlying health system. As with any business, location is a critical component to the success of a PLHP. The most suitable place for a PLHP is a region where the health system has a large share of a consolidated provider market and the level of payer consolidation is low.

Common Sense Health Service Purchasing: Medical Shopping 2.0

By | HCEG Top 10, Costs & Transparency


In a world where consumers can quickly and easily compare costs and buy nearly any item they desire online from cars to plane tickets it is safe to say that consumer’s expectations around the purchasing experiences are higher than ever. However, it’s not just the retail sector that has figured out how to streamline these web-based and omni-channel encounters. Online banking, travel, hospitality and other service-oriented organizations have been quick to follow its lead. Yet the health care industry has lagged far behind in these efforts. There are many reasons for this delay, including the following factors:

  • Health care pricing is incredibly varied and involves a complex interplay between each provider’s negotiated rates with the payer and the consumer’s own benefit design and deductible balance.
  • Provider bills are reconciled and payments are received weeks or even months after service is rendered through the claims submission, adjudication and reimbursement process with the insurer.
  • Health care decisions were not always as consumer-driven as they are currently. In the days of HMOs and other restrictive plan designs, providers and payers served as gatekeepers often deciding where, when and what kind of treatment was best for a patient.
  • In the recent past, the insured’s cost share for utilizing health care services was significantly lower. Most of the insured’s cost resided in the premium payment. With little or no financial out-of-pocket responsibility at the point-of-service, consumers were decidedly less concerned about comparison shopping for care.

Shining a light on cost variation and avoidable utilization

There is no doubt that consumer concerns about their rising share of costs and experience dissatisfaction are well founded. Many experts in the industry will admit that there is widespread pricing failure and lack of a common sense experience across the traditional health care system. Cost variation within and among payers, providers and geographies is widespread. One Blue Cross and Blue Shield Association report shows that costs for knee and hip procedures can vary by as much as 313 percent. Another industry report shows that for MRIs, the most expensive hospital in the nation has prices twelve times as high as the least expensive hospital. However, cost variation also plagues the ambulatory care side of the industry. Certain out-of-network providers bill up to 100 times more than other providers for the same services. Research shows that 71 percent of emergency room visits could have been avoided through consumer selection of more appropriate, lower-cost care options.

Transparency tools fall short

Many health plans have certainly attempted to make health care service costs and decision-making better for consumers. Most payers have implemented some type of transparency tool for their members. However, there are problems inherent in using this approach as a standalone band aid approach that addresses a symptom (unknown price estimates pre-service) and not the root cause (pricing failure in health care, known and reliable prices pre-service). These tools are not electronically actionable or transactional, and are often inaccurate, resulting in surprise consumer EOBs that dismantle consumer trust and confidence instead of building it. That’s because pricing information in transparency tools is often based on batch, not real-time, data, regional allowed amount averages at worst, or at best, historical paid claims costs. However, even historical claims payment information can easily become outdated as provider contracts change and it is more limited in its usefulness in rural areas, where a health plan may only have a small sample size of data. Consumers inherently doubt and distrust the accuracy of price quotes or estimates that are not immediately transactional or binding.

Many consumers also find these first generation price transparency and cost estimating tools limited in relevance for everyday health care needs. That’s because many of these tools are geared towards high cost acute services. Most also lack instant gratification transaction processing capabilities and pricing assurance. Perhaps it’s not a surprise then that while industry surveys show that 98 percent of health plans say they offer cost calculator tools, only two percent of members actually use them.

Addressing the shortfalls of today’s fragmented system

Consider the convenience and value of the real-time e-commerce purchasing approach compared to the traditional health care shopping and transparency model. In the traditional model, consumers have to seek out information from different stakeholders and avenues. There is no consistency, convenience or sense of ongoing engagement. Consumers may turn to their health plan for information about network providers and benefits, search for provider reviews on third-party websites or by asking friends and family, and then utilize transparency tools to approximate their costs. Then they must contact providers directly to confirm network status and schedule office visits. Finally, payment itself can be a complex interplay between point-of-service payments such as copays and additional balance payments submitted via mail after benefit reconciliation is complete, and this process typically takes more than 30 days.

This fractured and disconnected traditional process can only be understood through research and heavy lifting from consumers actively seeking out information from all of these stakeholders in a variety of different ways. Expecting consumers to navigate through this maze of information seeking and experience is clearly one reason why health care has failed to effectively engage, activate and influence consumers enough to significantly move the needle on cost and quality. This legacy process is disjointed, frustrating and time-consuming. As a result, many consumers will simply give up trying to make an informed decision and will select providers based on factors such as geography and availability.

Using e-commerce strategies to enable health care purchasing modernization

In order to support consumers throughout their entire health seeking journey, health care organizations must borrow from retail and other sectors with proven consumer engagement strategies and successful histories of transforming into digital enterprises. The global e-commerce industry saw impressive growth in 2014 with goods and services worth $1.5 trillion bought by shoppers via desktops, tablets and smartphones. Experts also predict that e-commerce sales will reach $3.5 trillion within the next five years.

Given the successful reach and consumer familiarity with the model, health care organizations should consider implementing a similar e-commerce approach that has a foundation of real prices and precision payments. Gartner analysts have predicted, By 2018, precision payment will replace value-based contracting as the bleeding edge of payment reform. Within the optimal e-commerce model, health care consumers can actively consider, compare, purchase and share experiences with various care options across different settings (e.g. telehealth or physical setting hospital, ambulatory center, urgent care, primary care, retail clinic). One leading company has already developed a viable, accessible and simple approach to doing just that.

The SpendWell Health e-commerce platform is a benefits-integrated, transactional consumer solution that allows consumers to easily access a service catalog with known prices and choose the health care services they want and need. SpendWell forges a direct digital connection from consumers to providers, giving health plans a new avenue to demonstrate value and create more informed, value-conscious members. Using this web and mobile health purchasing resource, consumers can make care decisions and purchase services with trust, confidence and no post-service effort.

Gartner analyst research has also linked the need for a personalized experience in medical policies and practices to precision payments. Precision medicine and precision payment are tied to each other in order to achieve the systemic changes that will improve the overall health and economics of the medical system. The Gartner research continues to exam these transformational dependencies, Precision medicine will fundamentally alter the institutions, vendor community, processes and technologies used in the payer industry to establish medical policy, authorize services and complete medical necessity review the gradual change from retrospective reimbursement mechanisms, typified by fee-for-service reimbursement and concurrent payment systems in value-based care, will move to prospective payment specific to a member’s current and future medical needs. Precision medicine, if combined with a new payer competency in precision payment, offers a new way of provisioning care that is appropriate to the individual, of high quality and financially effective.

The buy now button for health care

It’s also important to note that the moment of purchase is a very powerful part of an e-commerce approach, converting consumer interest into action and initiating a transaction to move the process forward. Transparency tools alone do not address this phase. To understand why it’s so critical, we can examine the potential parallels with today’s most successful retail models. A consumer may read product reviews on Amazon to compare the cost and quality of a particular product, and then immediately (and easily) make a purchase. In this way, the buy now button serves to help close the decision-making loop. Similarly, an e-commerce approach to health care services like the one developed by SpendWell supports consumers from consideration to evaluation, purchasing and post-purchase perceptions. It converts initial interest into an actual transaction with recurring options, just like auto-refill at a pharmacy but for health services and products.


Author: Bill Gaynor

Strategies to Improve Health Plan Margins on Public Insurance Exchanges

By | Interoperability / Consumer Data access, HCEG Top 10


We’ve analyzed the poll results from our webinar on Strategies to Improve Health Plan Margins on Public Insurance Exchanges. Get a firsthand look at the results. On March 29, 2016, we held a webinar in conjunction with AIS Health which gathered leading healthcare executives from health plans, health systems, and consulting firms. This presentation offered a valuable look into how qualified health plans (QHPs), and insurance carriers participating on health insurance exchanges, may minimize financial losses and achieve greater success. Offering a in-depth look of our reporting and analytic techniques for health plans doing business on ACA exchanges, the webinar polled participants on key topics relating to the current healthcare landscape. Here’s a sneak peak into the results.

Poll #1: How is your organization handling its healthcare exchange analytics?


Voiced by the vast majority of respondents in our data set, organizations are handling their healthcare exchange analytics in-house via a developed process or solution (52%), followed by utilizing an outside vendor (16%), does not apply to my organization (20%), and lastly, have not decided (12%).

Poll #2: Currently, what is your biggest financial concern relating to your exchange business?


By a landslide, the majority of respondents have selected Medical Loss Raio as their biggest financial concern relating to their exchange business (57%), followed by does not apply to my organization (19%), User or Per Member Per Month (PMPM) fees (9%), high administrative costs (9%), and costs related to technology (4%).

Poll #3: Which of the following do you anticipate as the next priority or opportunity for health payers?


Our poll indicates that among our participants, the next priority or opportunity for health payers will be automation & performance automation (44%), followed by regulatory & health reform mandate compliance (27%), membership retention (16%), and privacy & security (11%).

For more information on this webinar, contact us at[email protected]or access the webinar recording now.

3 Key Takeaways from Our #HIMSS16 Experience

By | HIMSS, Events

Blog-Banner-for-Pardot_HIMSS-REACTIONOverall, #HIMSS16 was an amazing experience for the Softheon team. As it was our first time attending the conference, we walked away with an overwhelming sense of optimism and enthusiasm for the future of our industry. As an industry leader in health insurance marketplace integration, we were thrilled to connect with so many forward-thinking organizations that were eagerly looking to take advantage of new opportunities while overcoming the challenges that exist within the modern healthcare industry.

The continued evolution of population health is of particular interest to our team at Softheon. New and innovative management techniques and tools are emerging to better balance cost savings with patient wellness. The emergence of modern value-based care models such as ACOs and patient-centered medical homes can be seen as an indication that population health has now been much more clearly defined and implemented in the United States.

Industry disruptors are moving forward with technological solutions such as mobile engagement tools, patient and physician portals and advanced analytics. In this environment, Softheon’s industry-leading exchange platform has been extremely well-received and we are elated with the outpouring of positive feedback from HIMSS attendees.

Our Top 3 Key Takeaways from HIMSS16:

1.Population Health is here to stay and has become a far more clearly-defined and widely-implemented model

2.The rate of maturation of management programs and technology in this space has exceeded expectations

3. Softheon’s Exchange platform along with our extended range of software solutions is increasingly in demand

As the industry continues to mature, we look forward to continued growth and the establishment of future partnerships that will enable an increasing number of healthcare payers to take advantage of our state of the art solutions.

Learn more about how Softheon can help your business break ground in the insurance market by requesting a copy of our whitepaper, “Turning an ACO Into a Health Plan: Distribution Platform Optimization”.


Mark Bethune, Business Development Lead-ACO Growth Strategies at Softheon


Change is the New Normal

By | Member Posts, General

Ray Desrochers, Chief Marketing Officer of HealthEdge

Regardless of who ends up in the White House after the current election cycle ends, it seems clear that health insurers will need to continue to address market change. New healthcare business models, including value-based benefits and payments, ACOs, Medicare and Medicaid expansion and the move towards public and private exchanges continue to stress the industry’s legacy technology infrastructure like never before. At the same time, consumers are demanding innovative new products and services, and access to information that is similar to what they have come to expect from every other industry. While there may be some debate as to which models will be most prominent during the next administration, one thing is clear: we won’t be returning to the one-size-fits-all healthcare models of yesterday.

Insurers are also increasingly focused on finding ways to manage and reduce their out-of-control administrative costs, and many are starting by taking a hard look at the technology that is driving their businesses. Many of these market leaders are consolidating their technology environments and eliminating the expensive, hard-to-maintain satellite systems and workarounds that have been negatively impacting their ability to operate high-performance organizations.
The result is many health insurers working to leverage modern technology to drive new levels of agility, efficiency and transparency, and to deliver the new options that their customers are demanding, all while driving down administrative costs.
Health plans that want to be successful in this new, consumer-centric healthcare marketplace must transform themselves, leveraging modern technology, to enable their organizations to rapidly address the changes that will continue to drive the market for the foreseeable future.
Ray Desrochers is Chief Marketing Officer at HealthEdge, provider of the only modern, enterprise-class software platform for health insurers. He is a frequent speaker at industry events and conferences around the world.

Time for Healthcare to be Top of Wallet

By | HCEG Top 10, Consumer Experience
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Adam Nelson – Vice President at NTT DATA, Inc

You may have seen on television commercials that a particular retail and credit card bank wants to know, What’s in your wallet? This question and the drive toward being top of wallet is a customer relationship management (CRM) theme that the financial industry has been focused on for decades. The intent is to drive consumers to use their credit card the most and become your bank for other services, from checking and savings accounts to auto and home loans. So, open your wallet and take a look inside. What do you see? Is it American Express, Target, or Capital One? Is it your driver’s license? Regardless of what card you see first, one thing is for certain, it was not your healthcare insurance card.

The financial industry knows how to create stickiness with its consumers attract them young via their first savings or checking account (pre-collegiate years) and then give them a credit card when they turn 18. They, then have a profitable consumer for life, which averages between 14 – 22 years in the banking industry and spans auto and home loan up-sell opportunity. However, for a healthcare insurance company, consumer stickiness, or top of wallet mindset, has been traditionally based on a once a year enrollment event or a quick scan of an Explanation of Benefits letter after a preventive or acute event (annual exam or hospital visit). This depicts an extreme lack of stickiness with a healthcare consumer, which the health plan desperately needs to have, but never considered prior to the healthcare event or as a primary focus on health management and wellness programs.

This last concept is an interesting one diet plans emerged in the 60’s with Weight Watchers, followed by Atkins in the 70’s, evolved to the 80’s era of Let’s Get Physicalgym memberships and where did we end up? With an obesity epidemic in America and abroad popularized by a shift in dining habits (eating out and eating faster), longer working hours (translating into less time for exercise) and a notable upswing in detrimental ingredients like sodium and sugar. All combined, these factors have contributed to an increase in chronic conditions that we all know; diabetes, heart disease, hypertension and the list goes on.

Now, we are entering an era of consumer directed health whereby individuals have more options, yet also want a better experience in what is being distributed as a more self-service model. So, how does a health plan create an ecosystem that is attractive to new customers (price driven), sticky (to increase retention), self-serving (cost effective), and helpful (quality of care with tangible positive outcomes)

Almost every health care insurer has some sense of a program that at the core resembles the start of a digital business similar to how retail has adopted an Omni-channel approach. In this approach, the intent is for the experience to be as similar as possible across any channel, be it in-person, phone, web or mobile, with the most significant outcome being the end state. The single qualifying question should be can the consumer do what they want across all channels; can they try, buy, return and rate and have a positive, familiar experience that drives recurring visits.

With a health plan, the same approach could be used and it is suggested that all the data and channels are in place or available today. The question to ask then is, How easy is it for an employer group or individual member (potential or existing) to shop, buy, use, and understand their benefits and all associated information from financial (FSA, HSA and maximums) to clinical (can I view my own trending lab and radiology results and vitals from multiple doctors) to prescriptions (what kind, how long, what was result) The answer is that while the data does exist, the information is not user friendly to view and therefore, no stickiness is generated between am employer or member and the health plan. In the end and with the push for consumerism, health plans, it could be argued, are almost driving too hard to the hoop for the proverbial silver bullet of a self-service, care-about-my-own-health, and know-what-to-do model.

Push the decision to visit a doctor, or any medical facility (ER, urgent care) based on funds in an HSA too hard and folks might begin to think financially instead of based on health. Shift from a $20 co-pay for a chiropractic visit to a pay-as-you-go until your deductible is met, and folks might not seek out or even research preventive care options. Sweep obesity under the rug because you only visit a doctor once a year for the free visit and there might not be multiple opinions pushing you with the cold, hard truth to change your habits or else. The balance is a fine line yet can be met with a few straightforward lessons drawing from retail, banking, and even some common sense

  1. Ease of Information Make it simple and visually appealing
  2. Person to Person Connection Make it easy to get past IVR and talk to a knowledgeable representative
  3. Interpret my Information Make it fast to view and highlight relevant information to me, typically financials and benefits
  4. Help Consumers Make Decisions help me to find the right healthcare when I need it! Whether the reason is preventive or immediate, think about the consumer experience. If someone calls at 2AM local time, chances are they need a nurse, not an IVR.

With the digital experience, consumerism and the ecosystem of data upon us, health plans that thrive will find ways to attract, retain and both qualitatively and quantitatively support their members and customers data is at the core; using it has been a decades old initiative and finally, the business processes and technology exist with suitable price points for health plans to become top of wallet.

NTT DATA welcomes you to read more at The Outsourcing Center in the article, The Shift to a Patient Centric Healthcare Ecosystem: Changing Minds, Medicine and Marketing

Adam Nelson is a Vice President at NTT DATA, Inc. Adam leads the Healthcare and Life Sciences Solution Offerings group focused on productizing service capabilities to bring predictable and relevantbusiness change to clients. Adam’s background in Industrial and Organizational Psychology helps tobring accelerated decision making and behavior change to complex enterprise programs; he has beenpublished and interviewed by Computerworld, Corporate Board Member Magazine, and Oracle’s Profitmagazine on the topics of IT Governance, Compliance, the IT / Business relationship, and Program Management.

The Shift to Value based payment: The Long and Winding Road

By | HCEG Top 10, Value-Based Payment/Care

The long and winding road
That leads to your door
Will never disappear
I’ve seen that road before
It always leads me here
Lead me to your door
-The Beatles

Screen Shot 2015-10-26 at 9.15.37 PM

Teresa DiMarco – Strategic Advisor at Leverage Health

If you?ve been around the health care industry for the last 30+ years, you know that the ACA and HHS? efforts around value based payment, ACOs and the like, are not new ideas. ? They have as their goal the same outcomes we?ve all been striving for over the past five decades: to achieve better health outcomes and patient care experience, cost-effectively.? We didn?t call it the Triple Aim at the time, but it?s the same thing.

The development of HMOs in the 70s and 80s was the mechanism, at the time, to re-organize health care delivery and financing in order to achieve what is now called the Triple Aim.? The initial and, some would argue, the most successful models early on were closed panel staff-model and group-model HMOs, where the providers took on full-risk and were also the payers?responsible for patient care, health outcomes and managing costs under a fixed budget, responsible for adequate patient access and for patient satisfaction, retention and growth.? We then expanded some of the principles of the staff model HMO to broad networks of providers which weren?t integrated clinically or financially, and thus had to use externally imposed controls to manage cost and quality.? We did so under the banner of managed care.

But, managed care hasn?t achieved all that we wanted, and managed care?s geographic and population reach has its limits.? Fee for service is still very alive, but not ?alive AND well? in terms of achieving our objectives.

So, now we are back to the future?or the future is back to the past?trying to figure out how we bring together providers of care, their patients and responsibility for financial and quality outcomes into one organization that is fully accountable and ?at risk?.? Thus, ACOs and value based payment models are introduced.? New names for the same concepts.

Now, CMS is tackling the unmanaged Medicare FFS program, which still represents a significant proportion of all Medicare program expenditures. ? Sylvia Burwell of CMS has announced that its goal is to have 85% of Medicare fee-for-service payments tied to quality or value by 2016, and 90% by 2018.? And, the target is to have 30% of Medicare payments tied to quality or value through alternative payment models by the end of 2016 and 50% by the end of 2018.? Alternative payment models, per CMS, include ACOs and bundled payment arrangements. Beyond CMS, the commercial managed care payers have been expanding their use of value-based payment arrangements for years.? The pace is accelerating.

What Does This Mean for Providers?

What does this mean for providers?? It changes everything–how they think, how they operate on the ground, how they make clinical decisions at the point of care, what information and tools they need, what data they evaluate, what metrics and outcomes they focus on, how they invest their capital, and how they make money or avoid losing money. Providers need to lead the coordination and management of patient care across the continuum of settings and specialties, for entire episodes of care.? They also need to understand the aggregate populations for which they are now accountable and to focus and manage all the health care resources to achieve broad population-based goals for quality and cost.? It is the long and winding road.

With all the focus on ACOs and value-based payments, you?d think that was the lynchpin of change. Yes, it?s a critical and fundamental element.? It is a required catalyst to undo the thinking and unwind the systems of care that were built and optimized under 75 years of FFS payment. But, these elements, while important, won?t get us there by themselves.? They alone won?t change behavior or create the systems of care that produce the outcomes we desire.

The Lynchpin to Change

The biggest tasks ahead, which are required to change the system, are also the most critical ones?changing the care delivery processes, workflows and point of care decision processes inside provider organizations. It?s transformational.? It?s a huge job. It will take significant resources, both human and capital, to execute. These process changes represent a total care re-design and a total change in how providers THINK about patient care, which now must include financial resource management and a long-term view of outcomes.

While this payment evolution is taking place, a challenge for provider organizations will be navigating across two very different financial models?FFS for some patients and value-based payment for others.? Practically speaking, it?s unworkable to manage patient care differently and have clinicians think differently depending on each patient?s payment arrangement.? Providers, at some point, will need to make a commitment to the new care delivery processes consistent with value-based thinking.? Likely, they will experience short-term hits on revenue and profitability on the FFS patients until the new models dominate.? This transition period will be painful, but the sooner providers ready themselves for success in a value-based world, the better positioned they will be to lead in their markets.? Ready-providers can actually help to drive more payer and employer business to the new models sooner, thus reducing the amount of time and business in the uncomfortable transition.

Interdisciplinary Work?Pulling the whole system of care together

Today?s world has providers operating in silos.? Primary care providers don?t coordinate effectively with specialists.? Hospitals don?t coordinate the transitions of care–from acute to post-acute to home care settings to ensure stabilization and recovery.? Behavioral care providers operate independently of primary care, but the two are interdependent for patient well-being.? Pharmacists and dentists operate on islands all to themselves.

What needs to happen in this care redesign for the value-based world is the coming together of clinicians of various disciplines, with experts in patient-service-experience and financial leaders.? Working in teams, the different perspectives will redefine the care protocols and workflows on the ground. ? Collaboration inside the delivery system, and outside the delivery system with new partners in the community, will take time, energy and, most of all, leadership.

Information technology and new analytic systems will play a critical role in supporting care delivery teams with the dashboards, long-term system-wide insights and patient-specific point of care data needed for decision making and care coordination.? Putting the right data in the right hands at the right time will be crucial. ? For example, a nurse case manager who is coordinating patient discharge needs to know what the most appropriate and cost effective SNF or ICF or rehab or home care options make sense for this patient, and have at his/her fingertips the data about which specific providers have the best outcomes and cost so the best choice can be made.? Then, he/she will need to facilitate, manage, educate, coordinate all elements of the execution of that care plan across a multitude of provider entities, partners and community resources.? And have the systems to track it.

Providers need to think and act like payers

Providers don?t need to design the new world order from scratch.? Much of the expertise and way of thinking about care at the macro-economic and system-wide level resides inside the managed care payers today. Population health thinking, care coordination and case management processes, reimbursement design, and other mechanisms for operating in a risk-based world has been the work of managed care/payers for decades. ? The population health information, the metrics, the claims systems, actuarial expertise, business processes, coordination of care tools and IT systems all exist there.

Some providers may think of managed care/payers as their nemesis. It?s understandable.? The payers had to insert themselves in the FFS system, trying to manage their risk from the outside; often, they imposed their management processes too late in the process to be optimal, and it all felt and was intrusive.? But, in an ACO environment, this thinking about value needs to move into where the patient and the provider live, and where care decisions are made.? What payers have, and what payers know, and what processes payers use, can all be brought to bear to help providers succeed in the value-based world.

So, collaboration opportunities exist not just across the health care delivery system of providers, but also with the payer world, in order to accelerate this transition to a value-based system.

The Long and Winding Road

Whether its primary care and PCMH models, Pioneer ACO models, or new BPCI (Bundled Payments for Care Improvement) programs coming soon from CMS for hip and knee replacements?. it?s all moving in the right general direction.? But, at the detail level, it?s still a great experiment.? CMS is trying new structures, algorithms, and payment formulae.? Providers are trying new structures and methods to manage care under the new reimbursement models.? Payers are trying a multitude of collaborative and control oriented models.? It doesn?t always work.? It will continue to evolve and improve.? It will ultimately lead us all to the value-based outcomes we seek.

It?s the long and winding road. We?ve seen that road before. It always leads us to that door [achieving value].

Teresa has 30 years of executive management experience in health insurance, managed care, healthcare IT, and in government-funded health care systems and BPO services (Medicaid, Medicare). ?Over her career, she was CEO of three tech-enabled health care services companies where she led them to market leadership positions and successful exits. ?She also advises companies, private equity, health care start-ups and venture-backed firms on growth strategies and operations. ?Teresa has a B.S. in Nursing and MBA from The Darden School of Business at the University of Virginia.

Healthcare 2016 Game of Thrones Shift: Consumer is King, Payer is Hero

By | HCEG Top 10, Consumer Experience

2015.09.22 - KingSetting the Stage

For those of you not familiar (or more appropriately heavily addicted binge watchers) with the hit series Game of Thrones on HBO, it is a story about the rise, fall, shifts and drifts of power within and between kingdoms, families and characters in a fictional medieval period. Make no mistake, even with all of the current technology and decades of knowhow available, the current healthcare system and process is feudal and the experience is draconian overly complex, hard to access and navigate, confusing and costly to all stakeholders. Consumers feel like they are being left hanging in the stocks (a medieval punishment device) in the town square when it comes to the current experience and costs associated with their health benefits and related purchases.

The good news, we are on the verge of emerging from this archaic, high resistance to change era into the next golden age of healthcare. E-commerce is the key that ignited change in other major industries (ex. banking and retail) and led to a significant spike in growth, improved experience, better efficiency and reduced costs. E-commerce and medical shopping are poised to have that same impact on healthcare.

Crossing the Gulf of Grief – Consumerism initiative driving healthcare

According to CMS Office of Actuary, of the $2.9 Trillion spent on healthcare in 2013, $381 Billion of that came directly out of consumer’s pockets for expenses other than healthcare premiums. While a significant portion of the $381 Billion was spent on co-pays, an increasing amount was spent on full cost healthcare from credit, debit, cash accounts or HSAs.

Continuing with the Game of Thrones analogy, the up and comers in a kingdom called Mereen are trying to create a better, more equitable society by challenging legacy cultural norms and the existing ruling factions. The citizens of Mereen are separated from the current centers of power think government payers, commercial payers and providers–by the Gulf of Grief. I liken healthcare consumers to the citizens of Mereen. The Mereen citizens are starting to realize their power yet struggling with becoming more self-governed and having increased voice, influence and decision making abilities. Sound familiar

Just like the citizens of Mereen, healthcare consumers will have to cross the complex, confusing and surprising currents of the Gulf of Grief to become sufficiently self-directed with less than exact information and imperfect navigational tools unless E-commerce, medical shopping and retail principles are more widely adopted by payers and providers.

Price, quality and access transparency to support the consumer experience

According to recent studies, 88% of healthcare consumers want to know their out-of-pocket costs before receiving health services. Only 46% of consumers are happy with their CDHP, HDHP benefits. The lack of insight into the true total cost of care pre-service is the #1 point of dissatisfaction among healthcare consumers. These data points above, as well as other indicators, point to an increased need for E-commerce and medical shopping initiatives.

By example, annual enrollment is a huge administrative burden on payers and confusing to most consumers. It makes sense to improve it. In my opinion, a disproportionate amount of resource investment and focus, especially in public and private exchanges, has been placed on enabling online benefit shopping and elections which typically happens 1-time per plan year. Would consumers rather have an online, more retail experience for shopping, comparing and electing their benefits Sure.

But, do consumers better prefer and need an E-commerce or medical shopping retail solution for how they utilize their benefits over an online enrollment solution Yes, consumers prefer E-commerce and medical shopping over online enrollment is what my informal user experience research shows. If the name of the game is to attract, acquire and retain policyholders for payers and patients for providers, then the benefit utilization experience is the primary area needing investment focus, improvement and automation. Commercial healthcare consumers on average access and utilize their benefits 13 times per year. Using the logic above of 1 enrollment experience versus 13 or more utilization experiences per year, wouldn’t logic indicate that payers and providers should prioritize and focus more resources on E-commerce and medical shopping initiatives.

If this is true, why are a disproportionate amount of payer resources tied up in online enrollment projects The answer is regulation. An online enrollment experience is mandated for public exchange benefits hence the resource prioritization on it. Lesson to be learned, healthcare and many other heavily regulated industries (ex. banking) typically do very little voluntarily in advance of regulation. That is why 9 states have or are considering transparency initiatives. That number is expected to grow. I contend that a transparency tool doesn’t go far enough in meeting the needs and expectations of healthcare consumers. The E-commerce platform will leapfrog traditional transparency tools and modernize traditional provider contracting, claims infrastructure, collections and payment processing which could save the healthcare industry $235 Billion.

Bend the cost curve in both medical and administrative expenses

PwC notes three factors that serve to “deflate” the 2016 medical cost trend: (1) The Affordable Care Act’s looming Cadillac tax on high-priced plans which is accelerating cost-shifting from employers to employees to reduce costs; (2) Greater adoption of virtual care technology that can be more efficient and convenient than traditional medical care; and (3) New health advisors helping to steer consumers to more efficient healthcare.

With respect to 2015, Milliman found the cost of healthcare for a typical American family of four covered by an average employer-sponsored preferred provider organization (PPO) plan is $24,671, up from $23,215 in 2014. The 2015 family costs works out to $2,055 on a monthly basis. Total employee cost (payroll deductions plus out-of-pocket expenses) increased by approximately 43% from 2010 to 2015, while employer costs increased by 32%. Of the $24,671 in total healthcare costs for this typical family, $10,473 is paid by the family, $6,408 through payroll deductions, and $4,065 in out-of-pocket expenses incurred at point of care. Overall, the U.S. healthcare economy is seeing increases in premium rates and drug costs, and decreases coming from efficiencies in virtual care and choosing lower cost options.

The primary drivers of cost reduction in most industries, including healthcare, are automation, competition and multiple or alternative channels of consumption or distribution. According to MDLive, a leading telehealth solution provider, 90% of PCP visits can be addressed by telehealth. SpendWell Health has observed 12 27% lower health service prices by providers participating in E-commerce marketplaces with upfront patient responsibility collections versus traditional network contract fee schedules and collections. An E-commerce or medical shopping solution with embedded telehealth has the potential to impact approximately $101 Billion of U.S. healthcare spend. Using these market principles and applying them to healthcare provides strong supporting evidence for E-commerce or medical shopping with embedded telehealth being one of the best and nearest term approaches to improving consumer experience and bending the cost curve.

About SpendWell Health

SpendWellTM is the leading health care e-commerce solution that empowers insured consumers to shop, compare and buy routine health services at actual prices. SpendWell’s online marketplace integrates benefit plans, removes consumer anxiety about surprise bills with upfront payments, eliminates patient collections risk for providers and reduces administrative inefficiencies and costs for payers. SpendWell transforms the traditional health care model for consumers, providers, employers,health plans and administrators into an online retail experience. SpendWell’s nationwide community of providers includes medical, dental, vision, behavioral health, chiropractic, alternative care, imaging and more. SpendWell is a wholly owned subsidiary of Cambia Health Solutions, Inc. Learn more at For more information about SpendWell, visit