Perennial laggards in terms of systems integration and customer-facing services, health insurers have spent the last couple of years catching up.

While complying with the Affordable Care Act (ACA) and participating in the public health insurance exchanges are the industry's most immediate concerns, it's the longer-term shift toward patient-centric health care that underlies the effort.

"We've heard loud and clear for many years now that the public is interested in bringing the growth of health care expenses under control," says Scott MacLean, chair of the Healthcare Information and Management Systems Society (HIMSS) and deputy CIO at Partners HealthCare. "We have a pay-for-service system, but the government and others are promoting the idea that we should be paying for health, not services. The direction that those paying the bills want to go in requires that hospitals and other providers band together."

Banding together means sharing data and integrating systems. "The landscape is moving away from fee-for-service medicine and into quality-based and outcome-based medicine," says industry analyst Janice Young, program director of payer IT strategies at IDC Health Insights, an advisory services and market research firm. This requires extensive integration of information for claims and metrics. "If the integration across processes, data and analytics doesn't occur, it's extremely difficult to compete with consumer-based products," she says.

Young says the ACA is accelerating these trends, since it's promoting the need for a 360-degree consumer model, which requires even greater system integration. But for a mid-size or large insurer that's grown through mergers and acquisitions, she says, there are typically a number of impediments:

* pre-existing contracts with vendors that lock the insurer into disparate systems

* a lack of consistency among the insurer's business models, processes and data

* technology silos that have grown around incompatible technologies and people who are beholden to specific processes that they are reluctant to modify, even to achieve the greater compatibility and operational scale required.

* new technology initiatives, such as wellness-oriented websites or utilizing data from a new class of medical devices, which requires data sharing among legacy systems and the new applications, can complicate the roll out and make integration efforts more demanding

A silo mentality among health care providers also can trip up insurers, who are beholden to them for much of their data.

"We have a very tight relationship with the provider community, which helps us engage our members," says Judy Feldman, CIO for Independent Health, a not-for-profit health plan with nearly 375,000 members in the eight western counties of New York State. "But with siloed systems that just doesn't work."

"From a technical standpoint, most medical systems can be integrated," MacLean adds. But to improve outcomes, the challenge isn't just to share data, but to provide information that a clinician can use. That involves a rigorous process of analyzing clinician workflow, which varies widely from institution to institution and even within the same hospital.

"A large-scale integration effort means you will probably change some highly compensated professional's workflow in a way they won't like," MacLean says. Competition among medical facilities is another source of resistance to breaking down silos. "Physicians and hospitals want to keep their patients, and one way to do that is to hold onto their information. So, at times, they have resisted this process. But as the patient payment process changes, there's less incentive for them to do that."

MacLean cites Medicare's stringent new rules on hospital readmissions as an example. As part of the government's sweeping effort to reign in medical costs under the ACA, Medicare has imposed tough financial penalties on hospitals and physicians that readmit patients for the same condition within 30 days of the original treatment. This puts pressure on all the providers involved in the patient's treatment to share data and coordinate care in order to get it right the first time.


Health insurers' efforts to integrate their systems and share data will be on prominent display when the state-based insurance exchanges launch in October. John Edwards, director of healthcare strategy and analytics at Pricewaterhouse Coopers, predicts that basic functions like enrollment and billing will be managed smoothly.

"Insurers have been refining their SOPs, so their staffs are very clear on how to handle and process exchange customers," which will be different from commercial group members, he explains. "They've been training their people to operate effectively in this new market."

Where they are lagging, Edwards says, is in marketing and product development for consumers. "There's been less focus on this to date," he says. "But the ability of consumers to change from one provider to another will induce the industry to reconsider its level of investment in customer-centric service." This is as opposed to what they're doing now, he says, which is refitting their existing systems for the exchanges.

All of these trends are playing out at Independent Health. Three years ago, the insurer began a series of inter-related system upgrades and overhauls to better adapt to the new patient-centric healthcare model. Most recently, that effort has been focused on preparing to participate in New York State of Health, the state's online health insurance marketplace and one of the 50 state-based exchanges mandated by the ACA.

"There's a huge amount of work to be done, but we've accomplished quite a bit and are really in a good position," Feldman says, explaining that to overcome the stove-piped nature of the insurer's systems, IT adopted a service-oriented architecture and migrated its data to a master data warehouse.

One example of the outcome is that the insurer's customer relationship management (CRM) system and the clinical system used for case management are now integrated, enabling customer service reps to engage with members for multiple purposes on the same call.

To help accomplish that effort, members of the IT team were paired with senior members of the various business units. "We didn't want to simply approach this as a system conversion," Feldman recounts. "The question was how we could get where we needed to be strategically. So we looked at the broader picture based on business capabilities."

Managing all of the relationships is extremely complex, and a huge diagram depicting all the application dependencies takes up an entire wall in Feldman's office. To complete the core system integration by 2014, IT is rolling out two major releases a month.

Preparations for the launch of the New York exchange are moving quickly ahead. "That project's in yellow, not red," Feldman says, laughing. Other initiatives to provide the underpinnings for a B2C patient health care model will take more time. Independent Health is working on projects to support customer personalization, one-to-one customer marketing and social media interactions, but these are mostly at the beginning stages.

If New York's newest health plan is a bit further along in its plans to provide patient-centric services, that's because it's entering the market with some big advantages over more established insurers.

North Shore-LIJ CareConnect is a newly licensed commercial health insurer that (at press time) will begin offering health plans to individuals and families in Long Island and New York City, starting Oct. 1, 2013. It is vertically integrated into Long Island's largest network of hospitals and other provider facilities, and therein lays its advantage.

"Because we've had the luxury of starting this from scratch, there are no legacy systems," says Charles Ottomanelli, CareConnect's CTO. "We are leveraging the North Shore health system and don't want to create redundancies."

North Shore will provide all of CareConnect's infrastructure, medical data and much of its analytics and back office processing, but CareConnect will interface directly with its customers and providers. "One of our core philosophies is that we own the customer and physician interaction," says Alan Murray, CareConnect's president. "That's our core competency. We are the face and the front-end of all those interactions."

For applications like enrollment, billing and claims management that it doesn't obtain from its parent, Ottomanelli says CareConnect is relying "99.99 percent" on cloud-based and other managed services.

Without the burden of legacy systems integration to contend with, the new health plan has gotten up and running very quickly. It has been testing its exchange enrollment functions for several months now and is confident it is nearly ready to launch.

CareConnect also is readying a swath of customer-service applications, reflecting its vision of a "complete health care solution that connects the consumer's coverage, health services and wellness needs in a simple, high-touch manner throughout their lives."

One of the most important is its call center, which it's building on the "Ritz Carlton model," Murray says. "We're not looking to be the best in health care with customer service. We're looking to be the best in customer service period."

Elliot M. Kass is a freelancer, often working with Insurance Networking News and other SourceMedia publications.

Register or login for access to this item and much more

All Digital Insurance content is archived after seven days.

Community members receive:
  • All recent and archived articles
  • Conference offers and updates
  • A full menu of enewsletter options
  • Web seminars, white papers, ebooks

Don't have an account? Register for Free Unlimited Access