Passage of the healthcare reform bill has set in motion sweeping changes in the way medical care will be delivered and paid for over the next decade and beyond.

Funding and managing expanded services are fundamental challenges to achieving the bill’s interconnected goals of improved care access, quality and cost-efficiency. They will require innovative approaches to align stakeholders – patients, providers, payors, and government – to help ensure that maximum value is received from every dollar spent. One option that’s gaining traction is Value-Based Benefit Design (VBBD). 

With VBBD, the goal is to keep members as healthy as possible. Payers offer highly personalized benefits that incentivize specific healthy behaviors for individuals who have or are likely to develop a chronic disease. People at high risk for a heart attack, for example, may not have co-pays for certain prescribed medications and physician visits, and might have their premiums reduced if they comply with their individual care plans.

Lowering out-of-pocket costs for high-value services not only helps prevent unnecessary and expensive care such as emergency room visits, surgery and hospitalizations, it also enhances members' quality of life. Patients participating in these programs tend to be more actively involved in managing their health, a boon for providers, and employers benefit from reduced absenteeism and increased productivity. Provisions in the healthcare reform legislation that mandate certain no-cost preventive services – and that allow employers to provide premium discounts and other rewards for employees who meet certain health-related standards – will continue to accelerate the adoption of this new generation of value-based benefits.

Payers that wish to offer VBBDs and other similar healthcare benefit innovations will need to adopt systems that enable new levels of transparency, agility and interoperability. One of the greatest barriers that payers face as they move into the world of 21st-century healthcare is their reliance on ancient, legacy software systems that were never designed to handle this level of complexity. With such systems, even minor changes typically require months or years of work by highly specialized IT experts, something that is no longer sustainable in a highly competitive marketplace that demands near-real-time configurability.

Another crippling weakness of these legacy healthcare systems is their inability to easily integrate with other platforms and to exchange data both across and between organizations. While most payers already collect a myriad of useful information from a variety of different sources, most of it resides in hard-to-access silos that were never intended to support the level of business transparency that the market now requires. As a result, most payors cannot easily aggregate and analyze these data, and they are unable to convert them into actionable information that will support optimal decision-making and business planning.

If consumers are to assume a larger role in managing their healthcare, which the federal government’s emphasis on prevention and wellness demands, payers must be able to provide them with immediate access to all of their information: benefits, provider network, health conditions, compliance with any care management programs, and the current state of their deductibles, limits and OOP maximums. Unfortunately, this isn’t possible with most legacy payor technology platforms.

Responding to the rapidly evolving imperatives of reform and the increasingly consumer-centric healthcare environment will require payers to adopt next-generation technology solutions – platforms that will enable them to truly be agile and innovative while delivering new levels of flexibility, transparency, operational efficiency, and customer service to the market.
 

Ray Desrochers is COO of HealthEdge, a company that provides the patented, award-winning HealthRules product suite.  The HealthRules offering includes next-generation claim processing and benefit administration, business intelligence, and portal solutions that are designed to allow payors to truly compete in the rapidly evolving, 21st-century healthcare marketplace.