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Healthcare reforms: Four ways for payers to thrive in the midst of change

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Though the deadline for complying with significant reforms of the affordable care act has come and gone, payer organizations across the country are still adapting to the newfound complexities of the evolving industry. Exercise of greater choice by consumers in decisions related to their health coverage and care is pushing fundamental changes in how front- and back-end processes are run. The efficiency and effectiveness of core operations are now a strategic advantage, not merely an instrument for saving cost. To meet the challenges of dramatic change and remain competitive, payers must be able to handle increased capacity while maintaining the quality and performance standards that their members increasingly expect. More specifically, customer and claims support systems, staff, and marketing strategies all have to evolve and grow to support the millions of Americans required to have insurance.


1. Modernize your processes

Keeping existing members happy is just as important as gaining new ones. Customers facing antiquated processing, slow claims turnaround times, or poor customer service are likely to choose another carrier when they are given an easily accessible choice. Sophisticated consumer interface technologies and analytics solutions that promise to keep your customers happy have yet to fully realize their potential as a strategic advantage. Enterprises need the ability to embed these solutions in processes that are optimized for peak performance in a targeted way.

By interconnecting business processes in a continuum from the start of the value chain through the end product or desired outcome, organizations break down traditional geographic and departmental silos that create business value leakages and hinder progress.

Looking at best-in-class performance not just within but also across industries to identify improvements in process steps helps exceed benchmarks of highly effective competitors. Targeting improvement initiatives on the key performance indicators (KPIs) that maximize effectiveness helps organizations focus energy and resources to reach peak performance and generate ROI faster.

2. Increase capacity

From enrollment to communications, payers should solidify their near-term staffing plans to ensure ongoing quality control, increased membership variability, team readiness, and talent retention. Conducting a comprehensive evaluation of process performance will root out any weaknesses in existing systems, making it easier to eliminate inefficiencies and boost the performance of existing teams.

GBS has resulted in improved scalability, lower costs, and optimized processes by industrializing operations across processes for leading healthcare companies.

But even with all this, it is difficult for any individual payer to accurately estimate just how much growth it needs to prepare for—and just how fast it needs to move—to make additional capacity available. Organizations looking to out-compete must define and adopt target operating models that provide the agility to respond to changes in volume and nature of demand faster than the competition. Global Business Services (GBS)—an evolution of shared services with a larger global footprint serving multiple functions—is a proven operating model that streamlines processes under a unified operating entity by decoupling business functions (combined with the advanced use of metrics, data-driven process management, specialized HR/organizational design, and effective IT). GBS has resulted in improved scalability, lower costs, and optimized processes by industrializing operations across processes for leading healthcare companies. These services can enable better decision making and nimbler pursuit of growth and adaptation to market contraction.

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3. Enable partners and technology

A wide range of partners, hardware, and software systems can support claims management, staff training, and other critical functions. With so much change and uncertainty, payers need to carefully select specific partners and technologies that support the continuity and stability of process, as well as those that help hold the organization accountable to critical and overarching change management timelines. Payers must also ensure leadership oversight in all partner and technology investments and look for opportunities to leverage convergence trends that help everyone in an organization increase transparency and capability.

Once a robust foundation of optimized processes is in place, technology solutions tailored to combine with the backbone of existing legacy systems and data can boost system and process performance without disrupting business as usual with the burden of a large-scale and costly change effort. Lightweight solutions such as robotic automation generate significant savings and improved quality and accuracy. Automation robots are cost-effective for implementing and practical for adopting since they can be easily deployed to work with any existing IT infrastructure and are flexible to be rapidly customized for any changes in process—a blessing in today’s volatile business environment.

4. Reconfigure plan portfolios

Most Americans have little experience choosing between varied coverage models or understanding the shared risk on which the health insurance pricing structure is based. To attract new customers, payers should reconfigure offerings to meet the questions, concerns, and priorities of this new target market. These portfolio adjustments will require a dramatic shift from business-to-business sales and communication strategies to business-to-consumer models.

Payers should be prepared to use advanced micro-targeting techniques and analytics to determine target customer profiles and assess the value and likely outcomes of new business strategy decisions. Social media monitoring will likely be used to help companies gather information on their target audience, pinpoint valuable market differentiators, and then help identify the best place to find target customers.

This has been authored by Sohil Goorha, Vice President Sales and Business Development, Healthcare at Genpact. This article was originally featured in Healthcare Payer News in July 2014.

For more information, contact, healthcare.solutions@genpact.com and visit, genpact.com/what-we-do/industries/healthcare-payer

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