This year at Gartner IT Expo, Mandi Bishop, Senior Director and Analyst at Gartner, discussed the (mostly) hype-free plan to digital strategy.  She was very focused on a pragmatic approach.  Digital strategy to her is about optimization 2017 and 2018 was about “learning how to pedal”  2019 is about optimizing the motion.  Your digital business strategy is probably about transformation. That means that payers have to transform and that means you have to optimize.

Mandi had three areas of focus:

1. Optimization is exciting
2. Customer experience means growth
3. Things to fuel customer experience

Optimization is Exciting

To create this plan, you need to know what leadership is looking for.  Are they looking for growth?  Are they looking for a Schwinn?

Answer:

1. For CIO’s, growth is the leadership priority
2. Digital is the second highest priority (but why do organizations keep spinning digital wheels?)

Quote: “The Biggest issue for digital is funding. Second is organizational innovation, third is insufficient skills and fourth is culture.”

Question: How do you get leaders excited about optimization?

Answer: Link optimization to growth.  align to the business

There are 6 categories to optimization

1. Improve existing revenue
2. Reduce medical expense
3. Reduce admin expense
4. Improve employee productivity
5. Enhance customer experience
6. Increase asset utilization

Every single one of these optimization elements has a growth tie-in.  For example, customer experience.

What Does Customer Experience Mean to Growth

Fact: Consumers with a positive experience spend 140% more than those with poor experiences (HBR)

Put yourself into members shoes.  How often do you see friction points in the experience?  Each element leads to a potential for churn. To optimize, you need to expand your idea of customer experience.

KPI’s

• NPS
• CAHPS
• Reduce call center volume
• Reduce call center hold time
• Fewer grievances filed

Functions involved:

• Sales
• Marketing
• Customer Service
• Don’t forget about care management
• Provider Data Management
  • the credentialing process is a pain point for providers
• Claims processing
  • Denied claims bring huge issues
  • Why should a denied claim be a surprise
• Utilization Management
  • Today’s prior authorization is painful
  • The AMA regularly surveys their physicians.  Last year, 86% said the burden got worse
  • 92% say process delays care
  • 78% said this leads to care abandonment
  • 92% say the process has a negative impact on clinical outcomes
  • 70% say they spend too much time in clerical work
  • In 2018, 90% of prior auth happens via phone and fax
  • It can last for weeks

All these interactions need to be effortless and optimized.

Just for prior authorization, you could:

1. Put in a request through EHR (integrate this)
2. Flow through to UM
3. Apply logic and business rules
4. Automatically send a request for more information
5. HL7 request will get you the medical record
6. An approval can be completed much faster
7. You can then notify both the patient and provider of the approval

Fact: Only 15% of prior authorizations are coming through standard HIPAA 278.  e.g. 85% of these authorizations are ‘special’  There’s a lot of room for improvement here.

Take the Apple Watch (OK, the hype is here)

Imagine that it now integrates to your systems. Imagine how a health event captured by the Apple Watch also kicked off a process with your company.

Immediate tasks for you to automate this:

1. Standardize on HIPAA 278
2. Make  prior authorizations accessible to members
3. Automate clinical data integration
4. Implement medical policy as logic
5. Automating prior authorizations workflows
6. Bundling common procedures (You don’t need to ask for every single qtip in this experience)

How do you fuel the customer experience?

Answer: It’s all about the data. Data is the core of the digital payer architecture.

• Customer of things platform
• Information systems platform
• Ecosystems platform
• IoT platform
• Data and analytics platform

Good news: 96% of payers has as a primary priority to get data and insights.

Recommendations

1. Find the customer experience and growth value in everything
2. Increase decision logic transparency to improve the experience
3. Design for data-sharing and partnership

Fact: 30% of US Healthcare Payers are focused on taking off the training wheels. They are focused on actual investment in these things.