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Customer Experience and Design

5 ways OBI + BPM + Member Portal = Success

What kind of equation is that? I can understand Member Portal, but OBI? BPM? Well, OBI stands for operational business intelligence. OBI is real-time, dynamic use of analytics that enables a service component to decide, based upon the information available, how to proceed in engaging with a stakeholder. BPM, or business process management, refers to the defining and execution of business workflows. Bringing the two together in a member (could be a patient) portal is a formula to success. All health plans today use a member portal to provide basic, on-demand services. Typically these portals include the ability to review past claims, search for a provider, plan documents describing their benefit program, find industry medial reference databases, enroll for benefits, fill prescriptions, view FAQs about their benefits program and even view and manage funds deposited in high-deductible savings accounts. But, as stated, access is on-demand. The members need to be well educated on the benefits consumption process to help themselves. In many cases, most just stumble through the process. To make matters worse, most of them don’t interact with our benefits site beyond the annual election process or, most importantly, when we have a need.

The time is right, and the solutions are there, for health plans to enhance the member services by moving from a passive, on-demand model to an active, assertive one. Doing so will increase member satisfaction, important for retention with the advent of Health Insurance Exchanges (HIXs) and consumerism in the benefits insurance marketplace, decrease the cost to serve, and increase the productivity of the health plan resources engaged in their services operations. Leveraging OBI and BPM, delivered through a mobile-enabled platform, is the way of the future!

To illustrate the opportunity to move to an active model, here are 5 use cases that could be enabled:

  1. doctor patient computer portalRisk categorization – Critical to engagement with your members is an on-going process that continuously reviews and determines each member’s level of risk. I’m partial to the John Hopkins ACG or Adjusted Clinical Groups system. It’s a good industry standard, actively maintained and used, performs well at the individual level, and does a good job at categorize both healthy members as well as those with chronic illness and/or events underway.
  2. Provider referral – This is a common need. Instead of assuming the member will search for a provider at the appropriate time or in response to a particular event, do it actively. Upon on a combination of factors including the following of an appropriate preventive regimen send a suggestion or alert to the member listing providers within a reasonable radius in the appropriate specialty. Suggestion can be based upon age or chronic disease occurrence, current healthcare utilization identified by claims, prescriptions and pre-authorizations or just wellness programs. An example could be a healthy, 50 year old with no claims history. Send a list of primary care/family physicians to them with the suggestion that they get a checkup and discuss the need for a prostate exam and colonoscopy.
  3. Target content delivery – Today, when any member logs in, they typically see a standard or common view. If there is configuration, it is typically around the type of insurance product or services purchased. Further leveraging engagement programs based upon the risk categorization and demographics of the member, dynamically deliver content that is appropriate and targeted to them. A challenge here would be recognizing the various permutations, but start with the most common and work from there. Worst case, today’s current view would be a default. At the very least, when a member logs in to the service portal for the first time, a quick questionnaire (basic health risk assessment!) could be done to set a baseline for engaging with them.
  4. Disease oriented preventive treatment programs (Focus on the big 5 – heart disease, cancer, stroke, chronic obstructive pulmonary disease [bronchitis, emphysema] and diabetes) – If the member has one or more of the major/common chronic diseases, such as diabetes, there is a well document regime of care that they should be following. Developing little “apps” or pockets of OBI and BPM/workflows around helping a member take care of themself can be delivered. You will have the risk categorization; claims show instances of care and prescriptions showing drug and consumable use. An app deployed on a smart device, delivered in a way to encourage participation (using gamification or other engagement tactics), that facilitates the member taking care of themselves, adjusting the suggested regimen based upon events underway, can help the member to maintain a reasonable quality of life in spite of the situation, be kept informed, educated and aware and provide a history potentially available to their caregivers. Employing gamification techniques specifically makes a game out of managing the available of test strips, routine glucose testing, or delivery of insulin. The achievement of certain targets could be accompanied by an award. Even something as simple as receiving a gold star for a certain performance. It’s even something that they could potentially tweet or Facebook about to family and friends.
  5. Annual enrollment planning – This can involve the predictive modeling aspect of risk categorization and past consumption of care. In the situation where there are multiple offerings that would be available to a member, providing them the ability to understand their past and future consumption can allow them to make the best financial decision for themselves. Today, the individual is left to try and figure this out on their own. When a member is part of a group offering, the selection list may not be very long at all, so there isn’t much choice, but with the risk in consumerism as a result of the new HIXs, this will be important. While the individual will go back to the HIX to elect or renew, there’s no reason why you can’t help them by ensuring that they are an educated consumer. Your goodwill and openness will drive retention.

There will be several challenges to implementing an active approach for member engagement. First, risk categorization: is your organization doing this, where’s it being done, and is the information accessible and usable at a member level? Second, you will need to incorporate a Workflow/BPM element and work with your clinical folks to encapsulate particular engagement programs (for example, chronic, preventive, wellness) into a workflow and define the conditions that would drive the use of each. Next, your portal and everything “within” it needs to be easily accessible on members’ mobile/smart devices. How about content management? What are your current capabilities with respect to this? Is it basic file storage and delivery or something more complex? And, bringing everything together, a portal solution incorporating analytics, workflow and content management is needed and a great starting point.

The pot of gold at the end of the rainbow is there. To get it will take hard work, an investment in time and people, along with a willingness to organizationally embrace change and a new perspective at engagement with members. With the move down the consumer path that Healthcare Reform is driving, the new individual consumer will expect, appreciate and respond to such an active, dynamic approach delivered in a “socially” conscious, mobile manner.

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