Right partner critical to enable core technologies to deliver community healthcare

The Situation: Community health plans are central to a population’s health for funding appropriate care and helping communities navigate the challenges and resources associated with the US healthcare system. The Dallas-based Parkland Community Health Plan (PCHP) is one such managed care organization, supporting approximately 200,000 Medicaid and CHIP beneficiaries in seven surrounding counties.

When PCHP experienced various structural challenges, its membership steadily declined for several years. To reverse membership decline and address the needs of its stakeholder communities, PCHP crafted a plan to adopt modern technologies and leverage data to enhance decision making. PCHP chose this approach to streamline operations and improve member experience by enabling technology for enrollment, care management, and claims and member management. To deliver to this roadmap, PCHP is working with a leading global professional services company helping PCHP transform its business, operating, and technology models for the digital era. The services company’s unique industry-based, consultative approach helps its clients envision, build, and run more innovative and efficient businesses.

Social determinants of health can be managed care’s best friend

Identifying relevant social determinants of health (SDoH), such as food insufficiency, access to safe transportation, or information for pregnant mothers, and addressing them effectively is key to impacting the triple aim of care (reducing the cost of care, improving health outcomes, and enhancing the experience of care).

The enablement of technologies is perhaps the most important driver of addressing SDoH. PCHP is working with its vendor to roll out a core administrative processing system (CAPS) to streamline various health plan processes, such as enrollment, customer experience, claims management, and reporting. This vendor is also driving smart analytics, giving PCHP insight into their membership and lending itself to powerful population health management.

PCHP leveraged its technology investments to address the barriers to SDoH in its community, particularly for pregnant women. It stratified the risk of approximately 40,000 members, then leveraged various communication channels to engage with those at risk and offer education about nutrition, facilitate regular doctor visits, and provide relevant information on breast pumps as an example. These efforts have led to a commendable 20% reduction in pre-term births. PCHP also provided new moms with mobile apps to address loneliness, a critical challenge of postpartum depression.

A contract’s structure can be the difference between success and failure

In choosing core administrative functions, health plans must weigh the investments and risks associated with the systems available. Evaluation often requires critical analysis of the desired outcomes, the impact on the business during implementation, financials, and the organization’s overall culture.

During PCHP’s analysis in partnership with the vendor, it learned of a construct that contracts for processes and outcomes rather than the technology. The business-process-as-a-service (BPaaS) agreement allows health plans to leverage the CAPS infrastructure capabilities rather than invest in building it independently. Smaller health plans typically don’t have much unspoken for cash flow to make large capital investments. Health plans that engage with BPaaS benefit both financially and operationally, given such a construct allows for flexibility and scalability without commensurate capital investments.

These outcomes can include meeting all state or Managed Medicaid requirements at a minimum with additional targets for accuracy, speed, and cost. The agreement can be dynamic with both upside bonuses and downside penalties. It is a construct that enforces a partnership with health plans and CAPS providers intrinsically investing in each other’s success.

Transformation is messier than a five-year-old’s birthday party

Enterprises attempt business and technology transformations all the time. Success is often hard to find given the various challenges such efforts face: implementation failures, budget overruns, schedule misses, and more. Detailed planning and communication are the keys to negotiating this minefield of potential challenges.

That is precisely the approach progressive health plans take. In collaboration with their partners, health plans should develop a robust end-to-end plan that includes right-sizing their headcount, hiring experienced individuals, empowering the right people in the right roles, and communicating across the enterprise regularly and consistently. To augment communications and talent, they should develop desktop processes and train their employees to use CAPS.

These deliberate actions result in a successful implementation for the health plan and give it both the confidence and the space to continue its business transformation and business expansion activities to support its community.

The Bottom Line: Partnerships, planning, and change management are critical to the success of transformational efforts.

A mature approach to a CAPS partnership, implementation planning, and addressing change management will drive a health plan’s successful CAPS implementation. While sometimes health plans have the advantage of a new CAPS implementation instead of a replacement, it is still essential they find a partner with the right experience and capabilities. Ensuring health plans can continue to conduct business without distractions from a large transformation effort requires significant planning. Lastly, facilitating the broader organizational engagement through a practical change management approach will help get the project across the finish line successfully.

A health plan’s technology enablement will typically include stabilization in the first year while improving the community’s health outcomes. In the second year, the focus shifts to optimization to realize greater value. A partnership with a CAPS provider will enable a health plan to scale operations as it grows with limited investment and taps into the industry-wide expertise the CAPS provider brings to bear. With this, health plans can be well on their way to growth and expansion into other markets.