Next-gen End-to-end Health Plan Operations to Enhance Delivery, Affordability and Efficiency

In order to respond to today’s challenges and unpredictable operating environment, it is imperative that we move on from organizational structures and connect silos to operate as one global team. While this holds true for every aspect of business, it is especially pertinent for health plans – connecting processes with a unified vision to function as ‘E2E health plan operations’, to become silo-agnostic, fully functioning and coordinated, with flawlessly operating teams.

End-to-End (E2E) health plan operations streamline the members’ entire healthcare experience from the enrollment process to policy administration. This can be accomplished by adopting a collaborative mindset, and enabling and empowering teams to place the customer at the center of all decisions and work cross-functionally to achieve clear outcomes.

Today, health plans are mostly segmented by business line with a complex network of interfaces running on multiple platforms. This means that tangible benefits to customers - like faster and better service – tend to get lost due to hand-offs between units and there are multiple back-and-forth steps and long lag times. This not only leads to high costs for infrastructure, operations, maintenance, support etc. but also means employing a large workforce with very diverse skills.

However, with changing times and evolving members’ expectations, additional IT cost and complexity is not an option. An E2E health plan operating model has the potential to reduce costs while improving efficiency and customer service across the value chain, from new business to policy administration and claims services.

Goals of E2E health plan operations

Health plans, today, are under tremendous pressure to reduce expenses and improve quality while remaining compliant and retaining their members through positive experiences and healthier outcomes. There is a fundamental connection between member satisfaction scores and increase in operational excellence.

Therefore, overall health plan operations need continuous improvements as well as end-to-end innovation. As we look ahead, cross-functional partnerships are expected to play an increasingly important role in achieving business goals, such as-

• Improved experience and satisfaction for member, provider and all other health plan constituents
• Reduced operating and medical expenses
• Regulatory compliance
• Building a system where the provider, payer and member are a cohesive unit
• Industry leading NPS and STARS
• Lessened administrative burden (prior authorizations/medical records)
• Devising an integrated clinical model (medical, behavioral, pharmacy)

To achieve these goals, we first need to establish a clear understanding of the guiding principles and constituents of E2E health plan operations.

Building blocks of E2E health plan operations

The first step towards development of an end-to-end health plan operating model is mapping of experience journeys, to understand how a member, provider and client engage with health plan operations. For example, for a health plan, a provider’s lifecycle can typically be divided into contracting and onboarding, care delivery, claims, billing and reimbursements, service, and performance management. Secondly, instead of falling into the trap of trying to improve existing processes or just a part of a process, advanced capabilities must be applied holistically to:

• Reimagine the complete customer experience – A holistic view of members is fundamental to E2E health plan operations. It helps design the optimal experience to meet changing consumer requirements, prioritization of member interactions and enabling consumer capabilities from contact through payments.
• Increased focus on personalized service –E2E health plan operations focus on achieving healthy outcomes through affordable individual care management. Central to this shift will be empowerment of members by providing them better tools and access to information regarding treatment costs and outcomes, thereby also reducing waste and giving members control over their healthcare.
• Define approaches that drive better functional integration –E2E health plan operations are all about team-work. Analytics can play a key role here by predicting treatment outcomes, ways to improve care management and sharing insights to enhance member satisfaction, and savings.
• Avoid rework, redundancies with analytics and automation –E2E health plan operations are based on simplified approaches, new techniques, analytics and automations. By addressing their workflow, data, and administrative requirements, health plans can improve their efficiency and enable interoperability with providers. Analytics can help identify the root cause for rework and automation can effectively improve process and financial accuracy.
• Offer round the clock operations capabilities –E2E health plan operations offer 24/7 capability, powered by onshore, near-shore, and global processing centers to offer round-the-clock, end-to-end service delivery.
• Leverage colocation wherever applicable/possible - Colocation makes for minimum cost and complexity, because the entire ecosystem of E2E health plan operations is readily accessible, resulting in high reliability and performance, enabling health plans to reach their customers and partners with minimal latency.

With these constituents in place, the path ahead involves setting clear objectives, goals and alignments across all functions and operations to achieve tangible benefits.

The benefits of E2E health plan operations

E2E health plan operations promise a distinctive experience, delivering results in terms of:

• Improved member experience and retention – Member experience and retention is increased through interventions in digital experience through offer personalization, electronic payment options, and other initiatives.
• Improved member outcomes - E2E health plan operations can help revolutionize care management through data and clinical expertise with sophisticated, real-time and transparent data flow. This will create evidence-based clinical pathways and protocols to help execute event driven provider and member engagement through a digital health ecosystem that is fully integrated with electronic medical records.
• Increased automation –E2E health plan operations ensure stability while delivering on commitments, by reducing cost structures through increased automation, identifying new features for digital channels, reducing paper form utilization and maturing personalization analytics.
• Business growth – To maintain and increase growth, E2E health plan operations are focused on being innovative about 1) An excellent commission payment system that is a game changer for brokers 2) State-of-the-art agent portal, effective online application processes and real-time access to leads, including mobile devices.

To reap these benefits, it’s essential that we treat end-to-end health plan operations as a single function, leading to flawless execution and best experience for members and providers. The ideal future to achieve end to end health plan operations could be a single technology platform that completely integrates health plan operations from product sales to grievance resolution with ‘no touch’ functionality as the fundamental principle for any health plan operating model.

While health plans have seen some early success with E2E operations, there are bigger objectives set out to deliver on the priorities of accessibility, affordability and quality of health care for all.

Guest Author: Subi Sethi – Vice President, Operations, Optum Global Solutions