A Possible Survival Guide for Regional Health Plan Expansion?

Regional health plans have generally flourished in the respective local markets that they have served. However, regional health plans only “extended” as far as the affiliated providers employed by the delivery system in a staff model or contracted in a group model. 

Today, competitive pressures from larger plans offering statewide (or beyond) employer group networks that meet their overall needs have put regional plans at a disadvantage and forced them to look at new ways to grow their business to remain competitive.

How do regional plans respond? Regional plans should continue to leverage the collaborative payer/provider relationships that exist in the original service area. With these relationships they can maintain ongoing optimization of collaboratively developed value-based care, enhance use of integrated payer/provider data integration, and further develop complementary business processes that can help to improve the customer experience.

Regional health plans should also focus on transforming business practices and underlying technology that can easily configure to better position and police relationships beyond the original service area. Where strategic business objectives might be slightly or significantly different between payer and provider, functions that were historically collaborative in a shared regional market are potentially competitive in an expanded one.

Some of these functions include:

  • Overall provider network management
  • Enhanced provider reimbursement / contracting
  • Customer-facing call center and self-help support to an increasingly disparate customer base
  • More policing of care/utilization management capabilities

The transformation curve is significant. The time required for planning, general design, eventual investment, and execution requires buy-in from all stakeholders. The risks are high for not positioning for growth. The risks (and poor results) are exponentially higher for organizations that fail to fully account for the overall investment required from underlying/foundational core systems integrated with other value-added applications/utilities.

Mike Comick

Mike Comick
VP, Strategic Partnerships 

Mike Comick is a HealthEdge Vice-President, leading the company’s Strategic Partnership program.  Mike has over 35 years-experience in health insurance core systems and associated business transformation.  Prior to joining HealthEdge, Mike was co-founder of Healthcare Technology Management Services (which was later acquired by Emdeon), a partner with First Consulting Group, and Vice-President of the Core Claims/Administration practice at CJ Singer / Gartner Group.  Mike has published company profiles, market win/loss reports and health plan IT aggregate budget analysis.

Case Study
Capturing New Business in a Competitive Landscape

Read this case study to learn how McLaren modernized its technology with HealthRules Payor and became more efficient, effectively compete in its market, and expand its business.

Subscribe to The 'Edge Report Blog