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Posts Tagged ‘AHIP’

AHIP Conference 2012: Day 3 Update

Malcolm Gladwell, staff writer for the New Yorker magazine and author of “What the Dog Saw,” “Outliers,” “Blink” and “The Tipping Point,” offered an overview of “Cowboys Versus Pit Crews: How to Build a Sustainable Health Care Delivery System” at our start of Day 3.

Gladwell was introduced as “gifted” at interpreting new ideas in the social sciences and making them understandable, practical and valuable to business and general audiences alike. Gladwell did shed light on a few industry examples including self dialysis and remote health as no-brainers in a cost-conscious future state of the healthcare delivery system, yet we still see extensive pushback from less progressive distracters that have a vested interest in the status quo.

I’ll confess; I did sneak out a bit early to get in line for a signed copy of “Outliers”…

Gladwell was followed by a discussion of the “Doorway to Health System Change” with contributions from a distinguished panel including: Michael E. Chernew, PhD, Professor of Health Care Policy in the Department of Health Care Policy at Harvard Medical School; Daniel Kessler, PhD, Professor at Stanford’s Business and Law Schools and a Professor (by courtesy) at Stanford Medical School; and, Scott E. Harrington, PhD, Alan B. Miller Professor; Professor of Health Care Management and Insurance and Risk Management, University of Pennsylvania.

Chernew’s research examines several areas related to controlling health care spending growth while maintaining or improving the quality of care. His work on consumer incentives focuses on Value Based Insurance Design (VBID), which aligns patient cost sharing with clinical value. Chernew suggested that depending on the new health care budget and the extent to which it will rise, it will determine the scope of delivery system impact upon the under 65 demographic. Chernew suggests that the American public is expecting a “perfect government in an imperfect market.” The role of government will require clarity regarding who ultimately needs to make decisions considering taxation, willingness to pay and disparity.

Kessler has written numerous articles and books about health economics and health policy. His current research interests include how tax policy affects medical spending and how vertical integration and other shared ownership structures in markets for health services affect the cost and quality of care. Kessler suggested that a key consideration is within the tradeoff between an “expanded safety net and cost control.”  Kessler further suggests that the root cause is in the “mis-set incentives” where plan decision ownership (employers vs. employees), transparency (competition amongst providers) and benefit design (latitude of coverage within a regulated plan) will require refinement in our future state health care delivery system.

Harrington has published widely on the economics and regulation of insurance and is a frequent speaker on health insurance reform, insurance markets, regulation, and public policy. Harrington has also testified before the U.S. House and Senate on insurance regulation and before numerous U.S. state legislative and administrative committees and he recently was appointed to the U.S. Treasury’s Federal Advisory Committee on Insurance. Harrington clarified 2 distinct approaches to Health System Change: Increased Government Control or Markets & Consumer Driven change. Where the current ACA places emphasis on increased government control, Harrington suggests that there must also be provisions to allow for competition and consumer choice.

Good news is that we won’t have to speculate on the Supreme Court ruling much longer…

AHIP Conference 2012: Day 2 Update

AHIP CEO Karen Ignagni kicked off Day 2 by addressing the elephant in the room…no Supreme Court ruling today. The fate of the Affordable Care Act (ACA) and “the Mandate” within would have to wait another day. Ignagni went on to remind the conference goers that similar attempts at state-based reform in the mid-90s resulted in 8 failures and no successes. Ignagni noted, “A key point regarding the 1994 reforms is that they were approved without a coverage requirement that brought everyone into the system. This omission sowed the seeds for a rapid and dramatic erosion in Kentucky’s individual insurance marketplace and eye-popping premium increases.”

Regardless of the Supreme Court ruling, there is still a clear need for shifting the cost of the care delivery system from the administration of care to the delivery of health outcomes.  Ignagni would like to see a continued or increased focus on Best Practices related to quality, cost and transparency within the end-to-end health care delivery system. Ignagni’s advice to AHIP is continued “Leadership, Innovation and Transparency” as the health care industry transitions into the execution phase of the roadmap for change.

And worth the price of admission alone, Paul Begala and Ari Fleischer were given an opportunity to foreshadow the Supreme Court ruling and offer thoughts on the impact to political climate.  Begala was the chief strategist for the 1992 Clinton-Gore campaign. Fleischer is a former White House Press Secretary for President George W. Bush. Now, both are colleagues as political commentators at CNN.

I feel I’m as qualified as anyone to offer a non-partisan overview of the session highlights especially since I’m a non-voting Canadian…

Fleischer felt that either the ACA will be ruled unconstitutional or Mandate alone, which in either case would generate GOP momentum and carry through to November.  Balaga suggested that 5 of 9 Republican Supreme Court Justices would ultimately default to partisan alignment and strike down the entire ACA, though the country’s satisfaction with future direction still trending to a second term for Obama.

Stay tuned…

AHIP Conference 2012: Day 1 Update

As referenced in the introduction to “America’s Health Insurance Plans (AHIP) Conference,” the decisions that will shape our nation’s health care are near. The Supreme Court Decision. The Presidential election. Implementation decisions within health plans that are shaping the delivery of care.

The intent of the June 20-22 conference in Salt Lake City is to address these factors head on. Many of our nations Health Plans intend to learn firsthand how these decisions will affect their organization’s efforts both immediate and long term.

Close to 200 vendors have either sponsored the conference as content providers or made their Leadership Team available to conference participants.  It is clear that Health Plans have access to an outstanding forum to access a variety of perspectives for navigating their agenda for change.

One theme that has already percolated to the surface of general discussion is the need for industry-wide collaboration.  There may have been good effort already allocated to SOA, 5010, ICD-10, ACOs and general Exchange strategy, but the time has come to transition from plan to action.

AHIP Day 1 included a review of Exchanges as one of the most pressing health care reform implementation issues for health plans, states and national policy makers. AHIP has dedicated a good portion of the agenda to review the policy and operational issues over the past year through examining the critical issues for health plans with a focus on the practical challenges.  Time well spent.

AHIP 2012 Conference Trend Watch

The 2012 AHIP national conference is almost upon us.  Our team will be at the June 20-22 event in Salt Lake City.  With all of the changes we are witnessing in the health insurance industry, this year’s conference promises to address the many needs of conference attendees.  Whether it is meeting regulatory compliance issues or preparing for health insurance exchanges, the AHIP conference will be the place to be this week.

Participants should leverage the AHIP conference to attend many of their peer organization presentations to learn from personal experience.  We look forward to visiting the exhibit floor to listen and observe what is being highlighted by the vendors as well as what our peers are saying and asking.  Health insurance companies can use this information to formulate how to address important issues.

Most importantly, enjoy the educational and collaborative nature of this event and network with your colleagues and solution providers so you can see the potential that can be achieved.  Take advantage of intelligence and expertise that will be found in Salt Lake City this week that will enable your health insurance system to be among the world-class organizations.

We would love to meet with you at the conference.  Leave a comment, catch up with us in person, visit our AHIP page, or contact us on Twitter (@Perficient_HC) to discuss what you think the hot topics for health insurance are this year.  Here is what we think:

SMART SOA FOR PAYERS

Perficient provides a competitive advantage for health plans looking to capitalize on the opportunities related to regulatory compliance investments, Health Information Exchange (HIE) initiatives, and health reform legislative mandates.

  • Healthcare Payer Shared Services Platform: Standards-based, secure connectivity platform for the exchange of health information across constituents, business units, and external trading partners
  • Automated business processes: Streamline IT architecture and speed implementation
  • Operating Cost Reduction: Transitioning transactions to the new platform, thereby eliminating the need for overpriced service providers
  • IT Maintenance Cost Control: Significantly reduced costs through the replacement of a heterogeneous Oracle/Sun Java and SeeBeyond middleware with a standards-based WebSphere implementation
  • Faster Time-to-market: Over three months’ savings per shared service leveraged for new applications
  • Improved Business Productivity: Due to increased operations visibility and system recovery capabilities

HIPAA 4010 TO 5010 CONVERSION

Perficient’s HIPAA 4010 to 5010 solutions are a full scope effort within your organization including:

  • Assessment: Identify the tools and technologies that best fit your environment. Clarify the benefits and opportunities you can expect. Define the people and process changes that will facilitate a 5010 upgrade program
  • Solution Roadmap: Define an actionable roadmap that clearly articulates the steps required for a successful upgrade. Align to business goals while mitigating risks
  • Implementation: Execute this roadmap with a flexible project approach. We work in concert with your team to deliver results at lower costs than our competitors
  • Business Process Improvement: Improve business processes for electronic data transactions (824 – application reporting, 820 – premium payments); transaction reprocessing and transaction management; new stricter enforcement of the HIPAA legislation; new regulations convert business associates as covered entities under HIPAA

ICD-10 IMPLEMENTATION

Perficient’s ICD-10 solution begins with a phased roadmap of coordinated projects beginning with a careful analysis of your healthcare IT applications and ending with the cultural transition of using the expanded code set.

  • Impact Analytics: Automates the identification and visualization of relationships between ICD-9 in historical claims data and corresponding ICD-10 code matches with eight separate levels of complexity and risk
  • ICD-10 Code Management: A medical ontology based code management system that allows modeling and mapping of ICD-9 codes into ICD-10 equivalents, and vice versa
  • ICD-10 Test Management: Automates the creation of large volumes of ICD-10 test data and shows the differences between results processed in ICD-9 and in ICD-10
  • ICD-10 Code Translation: A scalable, high-performance translation engine that enables ICD code translation (forward/backward)
  • ICD-10 Consulting Services: Provides expert support for the software toolset and services

Health Insurance Consumers: Let Them Eat Cake

Last week I read an article in TechCrunch called “Cake Health, The ‘Mint for Health Insurance’“.  This article is about a new start up, called Cake Health of course, and it really got my attention.  Cake Health aims to rid healthcare consumer of their headaches, and that’s quite a lofty business model considering the current state of things.

Cake Health is an online solution that prompts users to enter their health insurance credentials into their system.  The system then analyzes their health insurance data and enables health insurance consumers to make better decisions.  It tells the member how much they are paying out of pocket each year, how much of their healthcare costs the insurance has covered, how much of their deductible has been paid, etc.  The system also provides reminders so that members don’t forget to set up important preventive medicine appointments.

Most interesting, to me, is the fact that Cake Health provides recommendations to consumers about the health insurance plans they should consider based on their consumption of health insurance services.  This will be increasingly relevant as the number of self-insured continue to rise.  Overall, the health insurance market is expected to grow to almost $200 billion by 2019.  As this occurs, the market will continue to provide solutions like Cake Health to help enable patients navigate through their health insurance data and explore options. 

The problem is, health insurance companies are not popular with their members.  As shown in a recent Forrester report, the health insurance industry ranks dead least in measures of consumer experience among the industries they track.  This could potentially remove some barriers to entry leaving and provide traditional health insurance plans with some significant hurdles.  Ultimately, health insurance companies will need to learn how to respond to this consumer driven market or pay the consequence of increased member turnover. 

In my opinion, they should heed some lessons from this new start up and engage members with their data sooner rather than later.  What do you think?

Lessons from this Year’s AHIP Conference

We were at the AHIP conference last week, and as shown in our earlier posts, we learneda lot at this year’s event.  The health insurance industry is at a point of tremendous evolution, and there are a lot of factors to consider.  Here are a few of the key themes that we took away from this year’s event:

Health Insurance Exchange: Health Insurance Exchange was the early winner in terms of themes that dominated conversation.  On the first day of AHIP, many attendees opted to attend the Exchange Conference exclusively.  Many of the items learned will help health plans navigate the increasingly interconnected healthcare environment that we will experience in the days to come.  Here is an interesting article that came out during the conference on how health insurance exchanges require an ambitious infrastructure.

The Rise of Healthcare Consumerism: As mentioned under our Utilization Management post, the changing role of patients within healthcare is causing a lot of changes to business processes and the traditional way of doing business in the healthcare industry.  Patients are being invited into the design of their care, and there are cost efficiencies that result in terms of reduced readmissions and the like.  Terms like “mass personaliziation” that have been big in retail for years are now making their way into conversations here at AHIP.  Here are some of the sessions that addressed this trend:

  • Understanding the Consumers’ Decision Process in Purchasing Health Insurance
  • Healthcare Transformation: The Movement Towards Individuals; Personalized Medicine: Its Value Today and in the Future
  • Mass Personalization: Optimizing Consumer Engagements for Improved Health Outcomes

Impact of Healthcare Reform:  This is a big topic anywhere you turn in the healthcare industry, or mainstream news in general, these days.  It goes without saying that this was a hot topic at this year’s conference.  More specifically, data is becoming electronic and healthcare organizations are becoming increasingly interconnected under healthcare reform measures.  This has generated ongoing conversation around how to prepare a health insurance business for these changes.  Some of the break-out sessions that dealt with this topic include:

  • Re-Engineering the Health Plan Business Model to Succeed in a Post-Reform Market
  • Four Imperatives for Post Reform Healthcare

Accountable Care Organizations: Conversations about Accountable Care is alive in both the provider and health plan industries these days.  Health Plans are making sense of the accountable care model and the changes that will need to be made to their business model as a result of this healthcare reform measure are being considered.  There were many education events on the topic of ACO.  They include:

  • Creating Sustainable Accountable Care Models; Population Health: The Reality Behind Healthcare Reform
  • Delivery Model Transformation: How will Business Models change with ACOs?

Creating Efficiency Through Health IT: As predicted in our earlier post about the rewards found in the pain that is ICD-10, there was a lot of conversation about transforming an organization with “next generation” technology as a result of mandated reform measures.  Our own customer, BCBS of Massachusetts, summed this up very well in a video earlier this year.  These themes were addressed in:

  • ICD-10: More than a Regulatory Requirement, An Opportunity for Business Improvement
  • Leveraging Health IT: Maximizing Your Capabilities to Create Efficiencies

Accountable Care Meets Analytics at AHIP

We are in San Francisco this week at the America’s Health Insurance Plans (AHIP) Conference.  This is a great event, and there are a lot of themes being evaluated by the conference attendees.  One hot topic from our blog is how to create sustainable Accountable Care models. This Thursday late morning session was standing room only and shows the strong level of interest in ACOs.

The session by Deloitte Consulting had an interesting twist – live audience surveys using text messages to create real-time bar charts of the results. For example, when the audience was asked what was driving the interest in Accountable Care, 56% said Rate and Margin pressure, while 40% said it was Outcome based payment terms, and finally only 4% said that dropping Traditional Barriers was the driver.  The survey indicated that dropping traditional barriers like the creation of health information exchanges or increased pressure for transparency aren’t top of mind versus addressing increasing rate and margin pressures.

Another key observation by the speakers was that collaboration will be mandatory in order to manage episodic care between the plan, provider and member.  In order to move from the traditional fee for service model to quality-based episodic payments then a moderate level of collaboration is required between the three parties and that introduces a moderate degree of risk as well.  Communication needs to be bidirectional and outcome focused to manage costs while maintaining quality.

When the audience was surveyed on the best approach for accountable care from three possible choices, the results were equally surprising.  The Medical Home approach garnered 56% of the votes, while the Integrated System approach was 32% and Condition Specfic ACOs (diabetes, obesity, heart disease) scored 27%.  What was surprising was that a vote for the Medical Home approach said that AHIP attendees liked an open market approach with an educated consumer versus the Integrated System which would be more like a public utility, vertically integrated and possibly monopolistic.  The Medical Home approach popularity may come from retaining an aligned competitive environment that would help drive down costs.

The final observation about building a sustainable model for accountable care is that the approach must be based on a strong information management foundation including enterprise data warehousing, advanced analytics and data governance.  In order to track outcomes for judging quality and episodic care management, then near real-time, holistic and integrated information will be critical to success.  The speaker admonished the crowd: “You have to compete on analytics!” He went on to observe that there isn’t a single source solution today, however a roadmap must be developed for technology to support the new world of accountable care.

The time to have a dialog on this technology roadmap for ACOs is now – what do you think?

A Fresh Look at Utilization Management at AHIP

We are in San Francisco this week at the America’s Health Insurance Plans (AHIP) Conference.  This is a great event, and there are a lot of conversations going on among conference attendees.  One hot topic from our AHIP Trend Watch post is the pressure health insurers are under with regards to Utilization Management.

Utilization Management is generally defined as reimbursement restrictions from a health insurer for a medical service.  Utilization management takes three basic forms: 1) prospective or pre-authorization of service, 2) concurrent review, and 3) retrospective review after the service has been rendered.

Utilization management is often viewed as a form of non-price rationing taking the operational form of a denied claim or ‘redirected’ service. Utilization Management within healthcare insurers is under pressure from four fronts:

  1. Shifting focus towards healthcare consumerism: People want to shop for their choice of healthcare provider services, thus challenging preauthorization processes
  2. Healthcare insurers working to reduce administrative costs to meet government regulatory pressures:  This makes it important to find an easy way to manage provider service contracts 
  3. Pressing need to modernize legacy IT systems: This includes implementing more flexible service oriented architecture to allow for more automated business processes
  4. Moving away from paper: The shift from paper claims, scanned documents and faxes to electronic claims, email and electronic content management (ECM) systems 

Tackling the modernization of legacy IT systems is key to addressing all four sources of pressure.  Forward thinking healthcare insurers are “wrapping” those mainframe applications as web services that can be integrated into business process management systems (BPMS).  BPMS software allows the flexible management of case creation, clinical review, appeals, audits and communication with the providers.  In addition, these more automated business processes can be depicted in easier to use web portal pages that are tailored to the work process of the individual.  That same portal can review a case, examine the electronic claims, review documents from the ECM system, and pass cases for approval to managers. Newer BPMS software includes business rules and work routing that can escalate cases and, in some instances, provide the health plan member with immediate feedback.

Instead of viewing the rise of healthcare consumerism as a challenge to utilization management, there is an opportunity for a healthcare insurer to gain competitive advantage.  By automating Utilization Management groups, the health plan could offer concierge service to help their members select not only a provider within the plan, but one that really satisfies their health goals. By coordinating members into chronic condition management programs or wellness programs, the goal of reducing costs and utilization will be much easier.  Integrating information into automated workflows will speed up responses to members, thus increasing member satisfaction, too.

Finally, adopting business processing management software will yield greater business flexibility.  One of the positive side effects of modeling business processes is that all of the steps that utilization management must do today become visible, thus allowing the analysis of where redundant steps are taken or shortcuts are available.  The pressures to reduce costs and allow healthcare consumers more freedom can be the impetus for taking a fresh approach to traditional utilization management processes.  Don’t let your competitors get there before your organization does!

2011 AHIP Conference Trend Watch

The 2011 AHIP national conference  is almost here.  Our team will be out in San Francisco for the June 15-17 event.  With all of the changes we are witnessing in the health insurance industry, this year’s conference promises to address the many needs of conference attendees.  Whether it is meeting regulatory compliance issues or preparing for health insurance exchanges,  the AHIP conference will be the place to be this week.

Participants should leverage the AHIP conference to attend many of their peer organization presentations to learn from personal experience.  We look forward to visiting the exhibit floor to listen and observe what is being highlighted by the vendors as well as what our peers are saying and asking.  Health insurance companies can use this information to formulate how to address important issues.

Most importantly, enjoy the educational and collaborative nature of this event and network with your colleagues and solution providers so you can see the potential that can be achieved.  Take advantage of intelligence and expertise that will be found in San Francisco this week that will enable your health insurance system to be among the world-class organizations.

We would love to meet with you at the conference.  Leave a comment, catch up with us in person, visit our AHIP page, or contact us on Twitter (@Perficient_HC) to discuss what you think the hot topics for health insurance are this year.  Here is what we think:

UTILIZATION MANAGEMENT

Utilization Management (UM) is a process for assessing the delivery of healthcare services to determine if patient care is medically necessary, appropriate, efficient and meets quality standards.

  • Healthcare and BPMS Services: Streamline Payor’s UM processes for higher productivity, and faster turnaround
  • Rules Engines: Create and maintain flexible business processes to meet changing marketing and regulatory needs
  • SMART SOA: Can streamline the IT architecture and speed implementation of automated business processes
  • ECM Practice: Incorporate document management into your UM process to speed review
  • Healthcare Payor Knowledge: Bring value to the design of your UM solution

 ICD-10 IMPLEMENTATION

Perficient’s ICD-10 solution begins with a phased roadmap of coordinated projects beginning with a careful analysis of your healthcare IT applications and ending with the cultural transition of using the expanded code set.

  • Impact Analytics: Automates the identification and visualization of relationships between ICD-9 in historical claims data and corresponding ICD-10 code matches with eight separate levels of complexity and risk.
  • ICD-10 Code Management: A medical ontology based code management system that allows modeling and mapping of ICD-9 codes into ICD-10 equivalents, and vice versa.
  • ICD-10 Test Management Automates the creation of large volumes of ICD-10 test data and shows the differences between results processed in ICD-9 and in ICD-10.
  • ICD-10 Code Translation A scalable, high-performance translation engine that enables ICD code translation (forward/backward)
  • ICD-10 Consulting Services: Provides expert support for the software toolset and services.

HIPAA 4010 TO 5010 CONVERSION

Perficient’s HIPAA 4010 to 5010 solutions are a full scope effort within your organization including:

  • Assessment: Identify the tools and technologies that best fit your environment. Clarify the benefits and opportunities you can expect. Define the people and process changes that will facilitate a 5010 upgrade program
  • Solution Roadmap: Define an actionable roadmap that clearly articulates the steps required for a successful upgrade. Align to business goals while mitigating risks.
  • Implementation: Execute this roadmap with a flexible project approach. We work in concert with your team to deliver results at lower costs than our competitors.
  • Business Process Improvement: Improve business processes for electronic data transactions (824 – application reporting, 820 – premium payments); transaction reprocessing and transaction management; new stricter enforcement of the HIPAA legislation; new regulations convert business associates as covered entities under HIPAA.