Urgent Digital Action Items for Healthcare Payers: Systems Integration, Data Standardization & Homogenized Processes—Everest Group

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ITO and BPO to grow steadily as healthcare payers play catch-up on digital solutions to navigate industry convergence and a shift in focus from B2B to B2C

We expect the healthcare payer IT-BPS market to grow 8 percent by 2020.

Healthcare is lagging behind other industries in adopting digital strategies, but radical changes in the marketplace—such as the advent of Walmart and Amazon as players in the space and the disintermediation of Pharmacy Benefit Managers (PBMs) like Express Scripts and CVS—are cultivating a fertile field for digital solutions.

Everest Group describes the current healthcare market as a shape-shifting industry, with once disparate players in the market—payers, providers, PBMs and pharmaceutical companies—converging, and the focus of healthcare payers shifting from business-to-business (B2B) to business-to-consumer (B2C). To successfully navigate these industry shifts, healthcare payers must adopt radically different, technology-based approaches to the way they serve members, reimburse providers, operate their internal systems, and adapt to changes in government regulations and programs, according to Everest Group.

“Take the typical healthcare payer’s internal IT systems and processes, as just one example,” said Abhishek Singh, practice director at Everest Group. “They are plagued with disparate information systems, fragmented member information, legacy IT burdens, insufficient transparency in financial records, and inflexible, manual processes. The need of the hour in this regard is systems integration, data standardization and homogenized processes. For this reason, we expect the healthcare payer IT-BPS market to grow 8 percent by 2020.”

In its recently published report, Healthcare Payer Annual Report: Payers Look at Digital to Reinvent in a Turbulent Healthcare Market, Everest Group examines in detail the myriad changes impacting the healthcare and life sciences market and describes specific steps healthcare payers need to take in four key areas to be future ready.

1.    Members: In the past, a “one-size-fits-all” approach sufficed. Those days are over. Payers must now focus on enhancing the customer experience by providing customized and tailored services, offerings and solutions to individuals. Web-based insurance channels, interoperable databases, cloud-based platforms and predictive analytics are digital tools that payers can use to overcome current challenges.

2.    Providers: Transaction- or volume-based payment approaches are being replaced by outcome-based approaches. As an increasing share of payments to providers is linked to value, payers must focus on both business and patient metrics. Access to a large amount of accurate data is a key asset in solving business challenges and mitigating pain points. Payers must focus on integrating systems to ensure seamless data flow, data management and analytics. Of particular importance is implementing a common analytical framework that continuously derives meaningful insights from the shared information.

3.    Internal systems: In general, payers’ internal systems can be described today as disjointed and fragmented. Payers must transition towards internal systems that provide a unified view of members, technology assets and resources. Currently, payers are struggling with the burden of legacy systems, manual processes and system inefficiencies. Payers must focus on data interoperability, process reengineering, change management and platform modernization.

4.    Government: Whereas our healthcare system has focused on volume rather than outcome in the past, going forward the focus will be on outcomes with lower cost. With a focus on cost-reduction initiatives, payers should focus on seamless data flow and system architecture to gain traction.

“We will see payers relying on sourcing partners to address data flow and integration; the adoption of digital levers such as mobility, cloud automation and analytics; and process standardization and reengineering,” said Singh. “These technology and operations mandates will be the key factors that determine whether payers’ are able to successfully transition to a future-ready state.”

***Download a complimentary abstract of “Healthcare Payer Annual Report: Payers Look at Digital to Reinvent in a Turbulent Healthcare Market”.***

About Everest Group
Everest Group is a consulting and research firm focused on strategic IT, business services, and sourcing. We are trusted advisors to senior executives of leading enterprises, providers, and investors. Our firm helps clients improve operational and financial performance through a hands-on process that supports them in making well-informed decisions that deliver high-impact results and achieve sustained value. Our insight and guidance empowers clients to improve organizational efficiency, effectiveness, agility and responsiveness. What sets Everest Group apart is the integration of deep sourcing knowledge, problem-solving skills and original research. Details and in-depth content are available at http://www.everestgrp.com.

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Media Contacts:

Andrea M. Riffle, Everest Group
andrea.riffle@everestgrp.com

Jennifer Fowler, Cathey Communications for Everest Group
+1-865-405-6380
robert@cathey.co

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Andrea Riffle
@EverestGroup
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