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Transforming the Health Plan Service Model

October 3, 2012
by Karthik Ganesh
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Health plans will need to manage a patient’s data holistically and seamlessly integrate with other critical players

For the longest time, health plans were considered “high quality” if they passed four basic criteria:

  • administered benefits effectively;
  • processed claims quickly and accurately;
  • offered a broad network of physicians, hospitals and additional facilities with fairly aggressive discounts;
  • and provided multiple channels for member inquiries (call centers, interactive voice responses, web assistance, etc.).

Even additional offerings (wellness products, disease management services, personal health records) were only considered important add-ons to ensure the health plan continually moved up the value chain in terms of services offered. Today, however, none of these services are considered differentiators anymore—they are merely core necessities that are now important to even compete in the industry. 

Changes in the industry landscape are forcing health plan leaders to reevaluate their value proposition while continuing to execute effectively on these core competencies. There is additional pressure on health plans to now be the engine that seamlessly powers the all-important patient-provider relationship. This is the genesis of the notion of the Accountable Care Organization. 

The care management conversation has evolved from being focused on medical management to holistic coordination of care across the benefits continuum. Seamless data exchange with external entities (pharmacy benefit managers, labs, health information exchanges, behavioral health organizations, etc.) is now a must-have to complete. The criticality of interoperability and patient data portability is only going to make this even more important in the future. In a nutshell, health plans will need to manage a patient’s data holistically and seamlessly integrate with other critical players across the healthcare continuum.

For a health plan to position itself for success in a post-reform era, there are four key differentiators that it will need to have: operational flexibility, simplified product “operationalization,” consumer centricity, and a superior integration toolkit.

This is the perfect time for a health plan to embark on a transformation of its core service model, thereby putting itself in a position to capitalize on the service expectations associated with the changing industry landscape. Key strategic imperatives of this transformation should include:


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