Driving Transformation in the Health Insurance Industry

HealthEdgeMarch 01, 2018

Today, more than ever, health plans are under continued pressure to stay competitive in the face of constantly changing market dynamics.

In fact, according to PwC[1], 88 percent of insurers are investing in technology to do just that. However, today a technology investment is not just about replacing existing legacy systems or adding new technology that supports the Internet of Things (IoT), for example. Instead, it is about adopting the latest technology to find innovative ways to transform health plan operations: reduce costs, improve collaboration and decision-making across the enterprise, react quickly to regulatory pressures and changing business models, all while striving to deliver the best possible experience for each plan member.

Andy Slavitt, Former Acting Administrator, The Centers for Medicare and Medicaid Services, identifies the three traits of a successful payer in today’s market. First, a successful payer must be adaptable; it must inspect every environment and understand how to win in each environment. Second, a successful payer knows its customers and understands their needs, in much the same way as Google® understands their users’ search needs. Third, a successful payer must design their people, processes, and technology around those needs to simplify operations. In general, a successful payer must embrace an agile mindset to transform its business.

It is a combination of changes to people, process, and technology that enables a payer to transform its business. To effectively compete in today’s dynamic market, the first step requires a payer to deploy a leading-edge infrastructure, with a core administrative system being a part of that.

According to a Gartner report(2), “most U.S. healthcare payers are operating on aging administrative systems that inhibit their abilities to keep up with the pace of change in the healthcare industry. Payer CIOs face pressure to renovate their administrative systems — beginning with the systems that support member acquisition and provide member services, to the systems that process claims and pay providers.”

A modern core administrative system is not designed to conform to existing processes. Rather, it is designed to enable a payer to innovate processes to complement the automation and more effectively operate. Without it, a payer will fall behind the competition, suffer from customer dissatisfaction, be unable to deal with regulatory changes or evolve to value-based models, and risk its business.

Once a payer transforms its operations, it can respond to, and even proactively address business model changes (e.g., payment reform), regulatory changes, evolving requirements from members and consumers, and competitive business opportunities to grow and expand.

HealthEdge provides leading-edge technology solutions and have helped many payers effectively compete, successfully grow their business, and overcome the ever-changing dynamics of the market.



[1] PwC (2017) Top health industry issues of 2018: A year for resilience amid uncertainty
[2] Gartner ( Refreshed: 18 October 2017 | Published: 26 May 2016) Healthcare Payer Administrative Systems Maturity Model

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Webinar: Health Plan Transformation - Staying Competitive in a Changing Market

Hear from two industry luminaries, William Copeland, Vice Chairman, US Life Sciences & Health Care Practice for Deloitte and Steve Krupa, Chief Executive Officer of HealthEdge as they share their experiences and guidance for health plans as they find innovative ways to transform operations to stay competitive in the face of constantly changing market dynamics.