JANUARY 25, 2011 / Issue 4
Featured Article
U.S. Healthcare – Turn and face the strange
It’s time to help your organization decide if it is a payer of claims or a provider of medical services.

By Carole Hodsdon

Changes … turn and face the strange.

Who knows exactly what David Bowie had in mind when he wrote that lyric in the 1970s, but he would be dead-on accurate if he was writing it to describe healthcare in the early 21st century. Well, he’d probably need to add something about fast, dramatic and sweeping changes, but you get the idea. Between ARRA, ICD-10 and the reform law, the American healthcare system is headed for a transformative tsunami unlike anything it has ever experienced. And since technology is poised to play a significant role in all of this, CIOs will increasingly find themselves in rather precarious, uncharted waters. They’ll have to turn and face the strange, you might say.

One article I read recently suggested that typical healthcare CIOs will be forced to modify, alter or adjust up to 90 percent of their technical systems in some way in order to navigate the industry’s changing regulations. I immediately thought back to my days in the health plan world and how I might confront something of that magnitude. And after my initial queasiness wore off, a different feeling emerged: Wow, what an opportunity this would be.

The seismic shift in the healthcare landscape is a chance for health plans to almost start fresh from a technology standpoint; to evaluate what they are, who they are and what they want to be; to find differentiators and leverage them to facilitate growth. And IT leaders can lead the charge and direct their companies toward new models that will not only help them navigate change, but capitalize on it – all while ensuring better care.

So, what are some of the things that will help health plans stand out in the world of Healthcare 2.0? How can paradigms be shifted? What are some of the differentiators to look for and build on?

The short answer, to put it bluntly, is “I don’t know.”

I think those things will be specific to each organization and will become evident through a good, thorough self-analysis. One thing I’m fairly certain of, however, is that practically no one is going to set themselves apart in the new healthcare universe by focusing as much on claims as most do now. The patient needs to be the primary concern, and that means becoming more service oriented and intimate with members by providing a unique experience and value-adds. It means focusing on medical management, analytics, rules and your network, not claims systems or eligibility or any of that other associated stuff.

I know a lot of people will read that and think “what about the claims system we’ve built and been modifying for the past 30 years?” Well, much like the healthcare system we’ve built and have been modifying for the past 100 years, chances are that it’s time for a different approach. Yes, there’s an inherent inclination to keep building and modifying what’s already there, but the winds of change that will soon be blowing in healthcare will be so strong and encompassing that allowing technologies to keep mutating will ultimately result in one big, ugly counterproductive monster. And no one wants that.

Instead, it’s time to let go. It’s time to realize that it may no longer be feasible to control everything within your four walls (as much as we’d all like to). It’s time to turn things like claims and eligibility over to companies that do nothing but claims and eligibility, and divert your resources to other areas that will give your business an advantage in the evolving market. Again, it’s time to help your organization decide if it is a payer of claims or a provider of medical services.

If it’s the latter, and I would bet the majority of insurers conclude that it is, you likely won’t have time to worry about claims and those things anyway. All the time and energy technology leaders once spent on developing and augmenting in-house claims systems will be devoted to developing and augmenting the optimal mix of care-management technologies. Things like clinical rules, analytics, disease management, networks, health information exchange, decision support, CRM and all the other fun technical components necessary for a health plan to really differentiate itself in the modern world will require the same amount of thought and consideration that now goes into worrying about claims systems. The philosophy will shift to finding ways to prevent claims in the first place instead of how to reduce or better manage them.

I suppose the bottom line in all of this brings us back around to Mr. Bowie and changes. Like it or not, they’re coming soon to a healthcare system near you. Yes, they’re daunting and game changing. But, as changes so often are, they can also be opportunities in disguise. Those who prosper in the “new” healthcare system will be those who turn and face the strange with open arms; those who are willing to put “the way we’ve always done it” behind them and re-think things a little in order to capitalize on new possibilities. For CIOs, it could be the chance of a lifetime.

Carole Hodsdon is EVP and chief technology officer, MEDecision. For more information on MEDecision www.medecision.com


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