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In a world where traditional claims management practices no longer work, health plans must embrace new strategies to compete in a changing market, said experts Wednesday at the 2013 AHIP Institute.
[See also: 5 ways to break barriers to successfully implementing payment reform]
Reimbursement and technology consultants led an interactive workshop for health plan executives, "Creating a Plan for Success: Positioning Your Organization for the New Health Care Economy," during pre-conference events at the U.S. health insurance industry's annual gathering.
The speakers told attendees how the arrival of innovative healthcare industry business models, such as accountable care organizations (ACOs), health insurance exchanges, value-based reimbursement and pay-for-performance, would impact core administrative processes at health plans.
"You have to reassess the nature of your market and determine your overall strategy," said Dean Farley, vice president of reimbursement consulting at Optum. "Will you pursue a claims-driven strategy or rely on population-based methods? And how will you transfer risk to providers?"
Farley encouraged health plans to reassess the payment models they've relied upon in the past. He ranked models from those offering the least risk to providers – such as fee-for-service – to those holding the most provider risk – medical homes and ACOs. Somewhere in middle lie mixed-risk models, such as prospective payment systems, pay-for-performance and bundled payments.
"Health plans should consider payment models both in terms of what they can most effectively administer, as well as the impact on relations with the provider community," Farley said.
Brent Shaback, Optum's vice president of information technology, said key opportunities now exist to "modernize technology portfolios to support the new business models" in healthcare reimbursement.
"Health plans must remove technology as a barrier to competition," Shaback said. "Plans must do this with an eye on customer service, as that will truly be a differentiator in the future."
Shaback outlined five areas in which health plans might leverage technology to capitalize upon the rise of new business models: (1) agility; (2) analytics; (3) simplification; (4) scalability; and (5) robust infrastructure.
"Today's technology is aging and inflexible," Shaback said. "Plans need to be agile with technology to quickly adapt to business changes."
In the realm of analytics, Shaback said health plans should shift focus from capturing and storing data to analyzing information, particularly as the industry moves closer to using real-time information to influence care. "Can you trust that your data is accurate and that it is relevant to make managed care decisions?" he asked.
Shaback and the other speakers emphasized the need for a strong alignment between technology and overall business plans. Technology infrastructure must be positioned to react quickly across the business enterprise, he said.
"A stable yet flexible technology foundation is critical to build upon," Shaback said. "Technology must enable participation in the new healthcare market, but technology change alone won't solve the problems of the new market."
The 2013 AHIP Institute continues in Las Vegas continues through Friday.
Photo used with permission from Shuttershock.com.