How Core Configuration Can Reduce a Health Plans PMPM

How many resources does it take to run the core configuration of your enterprise?  What type of custom external tools are required to build and maintain the configuration?  What are the financial impacts associated between the complexity of the configuration in a system and the cost per member per month (PMPM) or total cost of ownership (TCO) figures? 

As we evolve into the next generation of core systems, these types of questions top the list for the potential vendors looking to modernize a core platform for a prospective health plan.  One thing is clear, as we continue forward in the market, the time of the core systems that require high administration costs in terms of the number of resources and custom solutions it takes to configure and maintain is coming to an end. 

Currently, the savviest health plans in the market are shifting from the predominant solutions for configuring the system with offshore-based services and/or custom-developed utilities and toolsets to ones focused on out-of-the-box automation enabled by best-in-class configuration.    

Can a system be both flexible and provide streamlined next-generation configuration capabilities?  Putting myself in the shoes of any given health plan in the market today for a core modernization and the surrounding ecosystem, one key focus would be on the core configuration and the level of automation that the system brings. 

Is the system's configuration overly complex, disparate, and requires custom external tools to build and maintain?  Can my current staff pick up the complexity of all the aspects of a system that need to be considered when implementing and maintaining my business?  Consequently, what does that ramp-up time look like?  The steeper the learning curve, the greater the chance staff will likely resist adopting the new technology, and the project suffers or fails outright.

In my career, I have seen far too many health plans that implemented their solutions 20 years ago and are faced with complete re-implementation of the existing platform.  Their current systems do not possess the flexibility nor the automation to provide the ability to implement enhancements to optimize existing configuration over time. The level of effort and analysis is simply too high when maintaining production states are the operational primary focus.

HealthRules Language

One of the biggest advantages of the HealthRules solution is the flexibility and streamlined structure of the benefit configuration. Using the HealthRules Language, a health plan is no longer required to pre-configure the system as a deterministic business rules engine and can eliminate significant levels of analysis and configuration effort as a result. The business user empowering automation associated with imports, exports, and automated claims reprocessing coupled with out-of-the-box near real-time reporting form the nexus of the next-generation claims processing platform.  Using this approach has revolutionized and streamlined the concepts of configuration.

Core administration software for health plans

Give your system the true litmus test.  How easy is it to map an industry code to a service or say how any given service will pay?  What is the level of effort to create a new benefit from scratch, push it to all the members in the system, or build a benefit plan in the system for a new employer group?  Suppose the answer contains solutions leveraging either offshore teams and/or external custom solutions. In that case, you can safely conclude the heart of your core system is not next-generation ready, and likely very difficult to reduce administration overhead impacting the critical PMPM and TCO figures through enhancement adoption and cyclical system optimization. 

About the Author

Dustin Rojas

Dustin Rojas, Senior Director of Sales Engineering and Strategy, HealthEdge
Dustin Rojas is a senior healthcare technology professional with deep expertise and extensive experience in many aspects of Healthplan Operations, and the Payer Software industry.  Dustin primarily focuses on collaborating with the Sales team and the overall organization to lend his collective experience to the achieve the overall strategic goal of "Crossing the Chasm.”  As Senior Director of Sales Engineering and Strategy for HealthEdge, he regularly works with Prospects and Senior Leadership to assist in current sales pursuits, in addition to collaborating and consulting on emerging services opportunities.  Prior to joining HealthEdge in 2019, Dustin spent 22 years in a variety of roles in the healthcare payer space with organizations that include Great-West Healthcare (Cigna West), and Cognizant/TriZetto.

Subscribe to The 'Edge Report Blog