The U.S. healthcare industry has weathered major disruption — perhaps even upheaval — over the past two years. Collectively, we've worked to address numerous mandates stemming from ARRA and ACA while also moving toward ICD-10 and HIPAA 5010 compliance, all amidst unprecedented global economic decline and uncertainty on several fronts. EHR deployment, meaningful use demonstration, MLR restrictions, and phase-one health plan deployments for essential benefits and regulated healthcare coverage have kept us all busy, while requirements for accountable care organizations (ACOs), health insurance exchanges and other new healthcare paradigms continue to take shape. Industry old-timers — us included — compare these conditions to the introduction of Medicare 50 years ago, which in one fell swoop created the largest impact on U.S. healthcare … until now.
Congratulations to the pillars of today's healthcare industry — the providers, health plans and pharmacy benefit managers — who have doggedly juggled new and proliferating regulatory requirements while continuing to provide high-quality care and coverage to the aging U.S. population. Much has been accomplished, and we're off to a great start. Unfortunately, there's no time for rest and reflection.
ICD-10 deadlines are ambiguous, but not gone, and most of the largest ACA provisions are still on the horizon. Consumerism, long anticipated, has finally arrived with physicians and their patients alike demanding the instant access to medical information that they have come to expect from the Web, mobile phones and tablets. Most healthcare companies are responding by drastically reshaping their business models — defining core competencies, evaluating business process outsourcer (BPO) options (both as provider and receiver of BPO services) and exploring tangential markets particularly for ACO participation. Soon the new strategies must be executed. Today's healthcare visionaries are taking this time to assemble the right technologies and capabilities and create nimble and powerful transformational platforms that will support them through the next stage of healthcare evolution. These leaders realize that 2012 is the year to “Build for Change.”
For health plans, next-generation healthcare requires moving beyond the traditional role of “payer” and simultaneously becoming a trusted advisor and health coach. Federal mandates are squeezing out classic differentiators for health plans — standardizing underwriting, product design and, with health insurance exchanges, the shopping experience — and consumers have increasing flexibility to switch plans, driving healthcare closer to a retail experience. Tailored service, and a branded customer experience across all touch points, is now critical for health plans' future success.
Conventional customer relationship management (CRM) systems are insufficient for accomplishing this. Most plans have contact-center functionality on one platform and multiple, separate systems for care management and sales. The systems are data-centric, lack flexibility and are hard to change. They do not work together and cannot provide a single view of the customer. Worse, they provide a fractured customer experience for members who are becoming less tolerant with generic treatment, particularly regarding their personal health and well-being.
Today, health plans need to deploy technologies such as business process management (BPM), decision management and dynamic case management to turbo-charge and personalize their service offerings. Dynamic case management orchestrates complex work encompassing numerous work deliverables and participants, each with their own processes and deadlines. Disease management programs and appeals processing, where physicians, members and numerous health plan staff are handling component pieces that need to be coordinated across the process life cycle, are common areas where the technology is applied.
Decision management technology determines what the next-best action is for the particular customer, applying adaptive analytics to update recommendations based on new information or actions taken during an interaction. Health plans today are using decision management to provide personalized, proactive service — alerting members to outstanding or upcoming healthcare activities, coaching them to meet their unique goals and interacting with them as one brand over numerous communication channels.
BPM, which powers market-leading CRM systems, brings a single customer view from multiple interactions, systems and data sources. It guides users — customer service representatives and members engaged in self-service transactions — through streamlined processes, orchestrating company rules and customer preferences, including when to interact by text versus IM chat, to optimize performance and customer satisfaction.
Best utilized when provided through a single platform, and deployed fastest when on the cloud, BPM, decision management and dynamic case management enable health plans to be more flexible, agile and intelligent, allowing them to take a customer-centric approach that delivers superior customer service. The healthcare leaders of tomorrow are adding these capabilities to their technology platforms today.
About the authors
Elizabeth Hart and Bill Marshall are both principals in Healthcare Industry Solutions at Pegasystems. Pega's Build for Change technology is driving transformation at three of the largest pharmacy benefit managers (PBMs), 13 out of the 15 largest health payers and more than 65 percent of the Blues network. PBM clients handle more than 55 percent of the nation's prescription volume; payer clients write more than 50 percent of all direct premiums. Learn more about Pegasystems solutions at www.pega.com.
