Reduce spending with care management

Feb. 3, 2010

Business-process management software enables the automation of goal-directed processes across people and systems, and continuously monitors patient events.

Today, cost concerns are greater than ever. With the rise of consumerism, individuals also are becoming more involved in their own healthcare decisions. Both patients and physicians alike are viewing health plans more as allies and also as important sources of critically needed healthcare data.

Fortunately, technology has changed, and the industry now has the tools it needs to quickly deploy new cost-cutting approaches and broaden its role as “health and wellness” facilitators. In addition, many health plans have already been using this technology to gain administrative efficiencies. Now, plans need to turn that power to clinical activities.

Health plans using BPM technology for care management have made impressive achievements. Plans report reaching 100 percent accuracy in their authorization processing, 55 percent reduction in the cost per case, with a similar drop in case-handling time.

Care-management activities at health plans, including utilization, case and disease management, traditionally operate in organizational stovepipes that use disparate, technologically immature systems. Several functions are still manual, requiring operators to toggle between systems and search through spreadsheets to find the rules necessary to make appropriate clinical decisions. Often, health plans have outsourced some of their care-management functions to external organizations, which further exacerbates the problems of missing integration and inadequate coordination.

For example, an unconscious, 40-year old man rushed to the hospital after being in a car accident would be managed by a nurse using a plan's case-management system. He may be well known to the plan's disease managers due to his chronic heart condition, but since that is a different group using different systems, the nurse handling his hospitalization has no way of easily accessing critical data, such as recent healthcare assessments that could be pertinent to the situation at hand.

When the case manager needs to authorize a new service for the hospitalized patient, she needs to submit an internal request to the plan's utilization department, which could involve rekeying of data already captured in the previous two systems. This structure is inefficient, slow and prone to manual error.

Business-process management (BPM) enables the automation of goal-directed processes across people and systems. It can link the multiple legacy systems currently in place for each of the care-management areas and drive whole-person care for individual patients, while simultaneously managing targeted programs for larger population groups. The technology continuously monitors patient events, looking through authorizations, claims, pharmacy data and more, and generates real-time alerts to care managers when it discovers alarming activity or behavior outside the norm.

The system guides users through processes, and presents relevant data intelligently when needed or requested, including a comprehensive view across the patient's activities and information, created from data pulled from the plan's multiple systems and documents. In this way, the technology ensures that plans are consistently administering the highest-quality care programs and that the programs are being continuously tailored to individual patients.

BPM systems also automate menial tasks such as sending correspondence and wellness materials, providing multichannel notifications to wide-spread patient-support networks, updating case files and keeping systems synchronized.

Health plans using BPM technology for care management have made impressive achievements. Plans report reaching 100 percent accuracy in their authorization processing, 55 percent reduction in the cost per case, with a similar drop in case-handling time. User training has been cut by a third, and processes have been moved to the Web channel for patient and provider self-service, thereby improving customer satisfaction and the quality of care outcomes. Additionally, the integration and availability of data, along with facile, real-time targeted reporting, enables effective physician benchmarking and peer review.

Plans using BPM for care management also can roll out new care programs. BPM business owners in the care-management space are able to add enhancements to their systems themselves, and can test which strategies are most effective. Business owners report changing BPM rules in as little as 10 minutes, and they can selectively deploy new changes to pilot groups so that program efficacy can be easily evaluated.

Certain technological features of BPM are proving helpful in accelerating adoption in care-management settings. One successful strategy is letting skeptical users verify for themselves that the system is following appropriate protocols, by allowing them to view the system's decision logic and process steps.

BPM software can be deployed and extended with familiar office tools, such as Excel spreadsheets and Visio diagrams, and its rules and policies are written in simple English syntax. This user-friendly, on-demand rule-and-process visibility, along with BPM's self-documentation capabilities, can be invaluable when plans must show compliance during routine regulatory reviews and high-stakes legal engagements.

Another successful care-management adoption strategy is deploying BPM in targeted “slivers.” While BPM supports the full spectrum of care-management activities, it can be deployed selectively in the areas of highest need.

BPM systems wrap around and enhance existing technologies and systems for quick deployments and fast results. Mature BPM systems promote reusability of rules, processes, objects and integration points, which means that deployment of later slivers go even faster. In this way, health plans promote gradual and methodical care-management transformations in which user acceptance grows as the BPM slivers prove themselves.

Elizabeth Hart is healthcare principal at Pegasystems, Cambridge, Mass.

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