Perficient Healtchare Solutions Blog


Posts Tagged ‘Managed Care’

Managed Care includes ID&stratification, UM, Case Management, Condition Management and/or Disease Management, and Wellness

Member-centric Care: Not without Business & Architectural RoadMap

If I had a dollar every time an Enterprise Architect said, “I have a Road Map,” and handed me the future state IT architecture (which is 5 years out) and proceeded to verbalize current to future IT while I madly wrote every word down in preparation for a Business Transformation Session to prioritize/re-prioritize initiatives, well you get the general thought here.  Not the way to be doing things.

The whole industry is going through business and IT transformation; however, Road Maps are never complete, unless someone is accountable for these deliverables (See

How can the business prioritize initiatives without a road map for understanding the IT implications… better yet, how can the business reprioritize initiatives without understanding the IT impacts? This has always baffled me.  Has it bothered you?

Visions have to be documented in many forms and various levels of details for the appropriate audience.  One size future state IT architecture does not fit all.

What are your thoughts?

Member-centric Care: Open source to the rescue?

A must read from my colleague, Martin Sizemore, entitled, “Is it time for open source in healthcare?”

Wow! This Business/Process with system enablement person, me, can understand this architecture stack.  Yes, now more than ever we need open source.

Prototyping Open Source for testing ICD-9 to ICD-10 with on the fly remediation before going to production in a collaborative environment with Payer and Provider.  There’s an interesting thought.  What are your thoughts?  It is ok to let me know that I have exceeded my knowledge on this one.  That is, I have gone too much into IT and need to stick to the Business side of things.  Glad to have Martin as the expert.

ICD-10 Revenue Neutrality Will Drive Collaborative Testing

I was reading my collegue Mike Berard’s blog, on ICD-10 Revenue Neutrality: A Strategic ApproachWe have discussed the importance of testing before production between Payer and Provider (e.g., Physicians and facilities). In his 2nd to last paragraph Mike proposes the following:

“The reality is that Revenue Neutrality verification is still subject to the availability of a Claims and Benefits test environment that will mirror production but accommodate GEMs and reimbursement schedule refinement on the fly. Does this mean that organizations will be subject to an infrastructure investment that also mirrors production? And will the test environment be subject to the same change control rigor of the production environment? I wonder if we have enough “maintenance widows” to support the number of changes to Claims and Benefits systems’ application logic before we know what changes to make the GEMs and reimbursement schedules…”

Based on my experience, I am not seeing Payer’s Business and IT departments addressing testing environments for Revenue Neutrality.  What is your experience?

I can see that Revenue Neutrality is being considered the end of the process so not much attention is being placed on it at this time.  Everyone is in ID and Stratification Mode.  However, as a process person, the end of the process is what drives the beginning of the process.  All critical information is gathered and tested at the beginning of the process to ensure the end-of-process can be completed and successfully reported.  If we are not testing ICD-9 to ICD-10 all the way through the process for Payer, Provider, and Member neutrality before we go to production, we must take a step back and revisit our Strategic Approach.

Mike concludes with the following:

“Revenue Neutrality may have an initial focus on billing and reimbursement based on clinical accuracy in procedural coding, but will ultimately depend upon remediation of information systems and close collaboration between the payer and provider for ongoing refinement of reimbursement contracts.” These are hand in hand with a Member’s benefits and out-of-pocket expenses for ICD-9 to ICD-10.  This should be tested and certified for our patients/members prior to production.  Otherwise, we are not member-centric.

Payers and Providers need to reengineer their processes to ensure remediation on the fly after going into production for Member-centric care with ICD-9 – ICD-10. Michael Hammer would not be very pleased with our reengineering efforts for member-centric care without remediation processes once in production.

What are your thoughts?

ACO – A Brave New Enterprise: Are you ready?

Racing towards an ACO and Population Management this year is a huge challenge.  A new enterprise platform is a must for an ACO to coordinate the changing of Provider and Payer processes and behavior not to mention the Shared Savings contracts which require new measurements and reporting: a shared dashboard.  Check out Martin Sizemore’s take and solution for this Brave New Enterprise.  Also, how are you going to leverage Cloud Technology?

During my years in consulting I have had the opportunity to work at a large local telecommunications carrier who wanted to get into long distance; thus, they had to open up their systems and serve competitive local exchange carriers.  Just 15 years ago the telecommunications industry faced a Brave New Enterprise.  Just as a local carrier had to go through third-party review and regulatory oversight, we now have a similar situation facing the ACOs.

The partners of the ACO need to start now on formal Enterprise User Group.  Yes, we are talking establishing weekly status meetings with all parties and a formal change request management process for the ACO.

What if multiple Providers want to change the flow and/or data extraction from/to the Brave New Enterprise?  This should be discussed by all users of the enterprise and prioritized in the appropriate release.

Changes will need to be fast and the ACO will need to follow an Agile w/iRise BPM.

Do you find it exciting to think of the Brave New Enterprise without the chains of a traditional SDLC?  Think of the mobile applications that can be put in place.  This white paper can help you to learn more.

The ACO BPM needs to be established.

Change requests will not be for just the Brave New Enterprise system, but will include process as well.  Think big.  The Telecom industry had to do so and it took years and lots of lessons learned. Avoid repeating the same mistakes since we do not have the time to re-invent the wheel.  Leverage whatever you can.  For example, Lesson Learned:  Start sooner rather than later….build with anticipation to manage changes to processes and systems in a formal consensus building environment.

What are your lessons learned from building and managing a Brave New Enterprise with parties that have to transition to a Brave New Relationship?  Do you have other industry comparisons to the Healthcare industry of today?

Member-Centric Care: Are we enabling the Next Generation of SMEs?

A struggle for the Payer/Provider Industry is how to prepare the next generation of Subject Matter Experts (SMEs).  Now more than ever you need the experienced Medical Directors, Clinicians, and Non-Clinicians on your multiple #1 initiatives.  Are you preparing your next generation of SMEs?  Yes, you do need the 20–25 years EE on the project team; however, you need the next generation of SMEs on your initiatives to be provided not just responsibility, but authority and VISIABILITY to the leadership team.  If you are placing all the responsibility on the well deserving EEs (which I say I am not worthy of them) who are eligible for retirement in the near future, you are missing the opportunity to establish, mentor, and enable the next generation of SMEs.  This is a wonderful opportunity to encourage knowledge transfer from Direct/Manager to Lead.  It is not easy for the experienced leads have to deliver on multiple #1 initiatives in reduced time frames with new technology and often do not have time to complete knowledge transfer (HINT: Ask for Help and Delegate).

The solution:  Now more than ever CTI/CIO/CEO needs to make sure that experienced EE SMEs are aligned with the next generation of EE SMEs.  They both need to be part of the team.  This will assist the experienced EE to delegate leadership of one or more #1 initiatives.  The next generation of EE SMEs needs the opportunity to present the status of their projects to leadership.  It is a learning process to document and present strategic vs. tactical updates to leadership in a concise time frame.  Staying up with technology and what is or isn’t working for the Healthcare industry really needs to be placed with IT and off of the business.  Even though businesses expect that SMEs are all knowledgeable of IT, it is just too much for any single business person to adequately cover business and IT in this rapidly changing environment.  What could happen is you may have a very experienced EE SME who has gone from being a Business SME to a Business/IT Generalist.  Has this happened to your team?  Are you on a team that has transformed the SME to IT/Business Generalist?

If you feel you are in this situation (i.e., low utilization of next generation of SMEs and overload of IT on a Business SME), then here is how you could leverage a Healthcare Consulting Practice.

  • Bring in a Business Solutions Architect
    • Sits on the business side and reports to the business
    • Healthcare (i.e., Payer/Provider experience) and IT experience (e.g., IT Architect)
    • Responsible for staying up on all IT industry best practices and changes in Healthcare
    • Responsible for delivering #1 business initiatives into a detailed architectural Road Map with the Payer/Provider IT practices (e.g., Enterprise Architect)
    • Responsible for transferring business and IT knowledge to the next generation of SMEs.  This could mean actual one hour per week sessions for planned knowledge transfer
  • Bring in a Healthcare Business Analyst that can flex to Systems Analyst
    • Sits on the business side and reports to the business/IT
    • Healthcare and Business Analyst experience working with System Analysts in translate the business “what” to system “how”
    • Responsible for capturing Business Requirements in a new BPM Methodology (e.g., Agile w/iRise BPM Methodology)
    • Responsible for transferring knowledge to the next generation of SMEs and Business Analysts
  • Bring in a Healthcare Systems Analyst to flex to the Business Analyst
    • Sits on the IT side and reports to business/IT
    • Healthcare and IT Systems Analyst experience working with Business Analysts in translation of business “what” and system “how”
    • Responsible for capturing System Requirements in new BPM Methodology
    • Responsible for transferring knowledge to the next generation of System Analysts
  • Bring in a Healthcare Project Manager to ensure the a detailed Business/IT workplan is completed and managed (NOTE: Avoid the high-level milestone plan to record IT hours only)
    • Sits on the business side and reports to business/IT
    • Healthcare and Project Management Experience (i.e., packaged solutions, business transformation, legacy systems, release management, etc.)
    • Responsible for PM of issues, change requests, and action items are following the client’s methodology/system (NOTE: Client PMs have portfolio responsibilities and are unable to stay on top of day-to-day PM)
    • Responsible for transferring knowledge to the next generation of Project Managers

Now you have a single team with clear responsibilities, reporting and transferring of knowledge to the next generation of SMES and taking the load of the IT industry knowledge off the shoulders of the well deserving EEs who are driving multiple #1 initiatives.

Member-Centric Care: Have we over turned every rock?

In my previous posts about the Member-Centric Care team, I posed several questions and gave my opinions to support them. Here is a review of what was discussed, as well as new thoughts:

  • Have we over turned every rock (e.g., process, operation, and IT enablement) to allow for member-centric care?
  • Let us assume that you have gone as far up stream in BPM…all the way to Marketing/Sales and Insurance Brokers/Agents, then Yesyou have overturned every rock for the Payer and Provider to collaborate.
    • Health Insurance Agents are the first individuals to touch a potential new employer and member and support existing employers and members.
    • Health Insurance Agents are paid through commissions to educate their clients for Consumer-Driven Health Care and Member-Centric Care.
    • Health Insurance Agents have a responsibility regarding plan, eligibility & benefits, and assisting with claims.

Member-Centric Care: Are we working on the correct priorities?

In my previous blogs, I asked if we were missing a key player in member-centric care and then provided my opinion. Here is a recap of questions and answers I discussed, as well as some new points:

Are we, business and information technology professionals, clinicians, and non-clinicians, working on the correct priorities for member-centric care that are facing our core team (i.e., payers, providers, facilities, third-party vendor, regulatory agencies, and members)?

  • It Depends — I love this one, don’t you?
  • The priorities have not been ranked by the business for IT.  Every priority seems to be #1, because they are #1.  As consultants, we need to assist the business in ranking their priorities based on the slightest variations of cost and SPEED TO MARKET.
  • We need to complete IT Transformation without the chains of traditional SDLC to meet SPEED TO MARKET:  The solution should be Agile w/ iRise for BPM.
    • See Perficient BPM Blog
    • At my most recent engagement, we worked within the client’s IT SDLC that did include Agile with a huge approval process and formal training. I’m not sure how iRise can be implemented within a big Payer without going through a tedious SDLC review committee, formal training for the team, etc. (i.e., there goes 6 months before the first kick-off meeting).  The client will continue to be Traditional SDLC unless the CTO/CIO/CEO bypasses the formal process and prototype Agile w/iRise following a formal BPM methodology.
      • Rapid changes and re-prioritization with monthly implementations are required NOW for the business to transform to Member-Centric Care.  IT must also transform as the business transforms.  One cannot happen without the other.
      • For the successful Payer and Provider to work on the correct Member-Centric Transformation Priorities, they must make IT SDLC transformation a #1 priority.
      • The successful Payer and Providers will be working to correct changing priorities in build if they allow IT to transform its SDLC to support BPM with the RIGHT tools.
      • What are your thoughts and experience of working within a traditional Payer and/or Provider to Agile w/iRise?
      • How do you add many off shoot links to a traditional SDLC?
        • I am familiar with the solution and experience of working with Payers and Providers to achieve rapid development once the links are set in the client’s traditional chain.
        • HINT: The only way for the above to be implemented is through knowledge transfer from the consultant to the client’s team members and leadership and support the client in their adoption from top down.  Employees are the stars that align and make HUGE transformation from in traditional environment
        • If you are a CTO/CIO/CEO for a payer or provider, what is your experience?  Is it possible?  How did you set consultants and employees to be successful?
        • If you are a Payer or Provider that is on the business and/or IT team leading the transformation to Member-centric care, how is it going?  What are your lessons learned?

Member-centric Care: Missing a Core Team Member

In my last blog post I asked if we have missed a core team member in member-centric care. My answer: In Sales there are the Health, Life and Supplemental Insurance Agents for employers and members that are responsible for mentoring members on plans, eligibility and benefits as well as understanding claims.

These individuals make a commission long after the initial open enrollment period of meeting with individuals for private health insurance.  Yet, their commission should somehow be based on or changed due to member continuation and satisfaction.

The question to the Payer is what role, responsibility, and payment plan you want for the Insurance Agent and/or Broker in today’s environment and moving forward.  Are they to become order takers? If they are paid commissions monthly after the enrollment, do you not think they should be mentoring the member through these rapidly changing times in order to encourage urgent care vs. emergency room?  You may want to encourage health fairs for HSA members to compensate for the lost cost with high quality annual physicals so less money is taken out of their pockets and more is kept in their HSA account.

Are we looking at a clinician and non-clinician relationship as seen today in care management; that is non-agent (order taker) and agent?  Would the latter be in-house or all contractors? Would the broker be a service or partner in an ACO?

What will the Insurance Agent/Broker role be in an ACO?  We still need that first human contact for sign-up and support for all the questions after the enrollment.

Should Insurance Agents/Brokers become contractors to Payer or to an ACO?  Remember they are licensed within the state which should be leveraged.

If you are a CEO, does your BPM include Marketing/Sales and the role/responsibility of Insurance Agent/Broker?  How will this be addressed with the ACO?  What can be done today to leverage, incentivize, and track performance not on enrollments?

I will plan to blog more about this since I have been an insurance agent for employers and private citizens and provided the following suite of products:  Multiple Healthcare Payer Plans, Colonial Life Supplemental Products, Life Coverage, etc.  I know the ins and outs of pharmacy too.

In addition, I have worked as project/product manager for a payer/carrier in Marketing/Sales and delivered on HSA, HRA, Old to New PBM and Enhancements to HMO, PPO, POS, etc.

My assumption is that we have not gone far enough upstream with this process and role for Member-centric Care, especially with an ACO.  We have worked on Payer and Association of Providers (networking) contracts and structure.

Most of my readings and exposure has seen a focus on the middle of a collaboration and rather ignore the Agent/Broker, which I think is a missed opportunity for member persistency and satisfaction for successful Member-Centric Care.

I am looking forward for your thoughts on business transformation with sales and Insurance Agents/Brokers.

Member-centric Care: Have we missed a core team member?

Recently rolled off a large payer, I am sitting back and reflecting on what is facing the healthcare industry today and what has happened over the past 15+ years (Looking at the forest rather than the trees).

1)       Are we, all business and information technology professionals, clinicians, and non-clinicians, working on the correct priorities for member-centric care that are facing our core team (i.e., payers, providers, facilities, third-party vendor, regulatory agencies, and members)?

2)       Have we over turned every rock (e.g., process, operation, and IT enablement) to allow for member-centric care?

I do not know the billions of dollars that our team (i.e., the core team mentioned above) has put into play to transition the member to being the ball that every team member knows when, where, what, and how to control at their point in time when the ball is in their hands.  Do you know the total costs for this team? 2010? 2011? 2012 projections?

Added to this, all the other team members have to be alerted, notified, IMed and prepared for execution if possibly the ball comes their way.  Sometimes the team has to pause to be sure the other team member is ready to receive (thinking pre-service and peer-to-peer reviews, transition from in-patient to home care, case management of critical conditions) and receive verification that the team member has received the ball.  Don’t forget tracking and replay.

Here is my assumption and am looking for your thoughts:  I think we have missed a team player and not over turned a rock (i.e., addressing numbers 1 and 2 above).

Do you know?  Below are several hints.  The answer will be on my next blog, later this afternoon.

HINT: We missed the same team player with consumer-driven healthcare (thinking HSA and HRA roll-out).

HINT: This team member is paid monthly by the Payer to provide services to members if called upon by the member.

HINT: The team member is state licensed

HINT: The team member is the first point of contact to bring a member into the network.

FYI – During my 15+ years of consulting and 10 years industry work, with a majority of both being Healthcare, I was at one time this missing team member.   I will have insights or perspective that may assist us in over-turning this rock/process/system.

I’m looking forward to your thoughts and answers.