According to TriZetto Group, Inc., with many components of the Patient Protection and Affordable Care Act already implemented, it is increasingly urgent for payers to successfully transition to a value-driven healthcare system that rewards top performers and high-quality standards.
Although opponents have promised changes and even repeal of healthcare insurance reform, the reality is that repeal is unlikely. While some health plans may be tempted to take a “wait-and-see” attitude, others are taking steps now to reduce their cost structures and improve efficiencies, enabling them to excel in the evolving healthcare landscape.
This issue brief focuses on the actions that health plans can take now to streamline core administrative processes, improve efficiency, reduce costs and grow profitably.
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 and Customer Service
Business process outsourcing (BPO) presents an additional, highly effective strategy for improving 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 BPO services can help minimize the amount that payers spend on administration.
The pressure to increase administrative efficiency has increased demand for BPO 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 hosting and management, too, can help health plans drive further administrative cost savings. An expert, payer-experienced vendor can host and manage a health plan’s applications, whether its systems reside onsite or in the vendor’s data center. And the benefits can go well beyond lower, more predictable costs. Application services can accelerate implementations, speed the resolution of software issues, and improve software performance and reliability.
Additionally, customer service can be a key differentiator. Successful health plans can improve member loyalty by demonstrating concern about their health issues and providing easy, fast access to care. Exceptional customer service can position payers to successfully brand their health and wellness programs, assuring members that not only is their doctor looking out for them, but so is their health plan.
Regardless of how healthcare reform evolves, payers will gain competitive advantages and build membership by shifting priorities toward streamlining administrative processes, improving patient care management and adopting new healthcare delivery models.
Reporters interested in speaking with TriZetto executives for further comment about this evolving trend in U.S. healthcare should contact Davida Dinerman at Schwartz MSL, firstname.lastname@example.org or 781-684-0770.
TriZetto provides world-class healthcare IT software and service solutions, including patented and patent-pending innovations, that drive administrative efficiency, improve the cost and quality of care, and increase payer and provider collaboration and connectivity. TriZetto’s solutions touch half of the U.S. insured population and reach more than 21,000 physician practices representing more than 75,000 practitioners. The company’s payer offerings include enterprise and component software, application hosting and management, business process outsourcing services and consulting that help transform and optimize operations. TriZetto’s provider offerings through Gateway EDI, a wholly owned subsidiary, include advanced tools and proactive services to monitor, catch and fix claims issues before they can impact a practice. TriZetto’s integrated payer-provider platform will enable the deployment of promising new models of post-reform healthcare. TriZetto is committed to the integration and convergence of technology systems, that enable its vision of Integrated Healthcare Management, the coordination of benefits and healthcare to drive more value from every healthcare dollar spent. For more information, visit www.trizetto.com.
The TriZetto Group