Older vendors are giving way to younger, innovative systems that have a member-centric and highly functional approach to utilization and care management.
Not price, not incumbency, but functionality is the key to winning and losing payers’ business, the KLAS Decision Insights Report 2019 indicated. Payers want highly functional, integrated, dynamic systems to support their shift into utilization and care management.
“While utilization management and care management solutions have been around for decades, today health plans are looking for modern technology solutions to help them manage multiple business lines and adapt to changing requirements for value-based care,” the report stated. “While innovation overall in payer HIT is not abundant, KLAS has seen an increase in decision energy mostly from relatively or completely new vendors receiving stronger consideration than existing or established vendors.”
Payers’ needs are shifting as they seek to capture a comprehensive understanding of population health while also delivering individualized care management. To accomplish this, they are looking for vendors that can accommodate their new objectives in the five focus areas of payer care management.
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Utilization management has been plagued by a lack of care coordination. Moving forward, payers want to pull their departments and networks together to provide member-centered, coordinated care.
Wellness programs remain a strategic factor in payers’ approach to disease management. Previously, payers’ approach to cutting costs in chronic disease management was case-by-case, disease-by-disease. While aspects of this approach must remain, the emphasis in chronic disease management strategies have now shifted to focusing on overall population wellness and rewarding healthy behaviors.
In case management, payers are releasing their grip on the process and forming partnerships with providers. They are moving away from a payer-centric solution and toward greater payer-provider collaboration to better address each member’s case.
Care coordination is becoming more tech-enabled. Previously, payers have pursued outreach and interventions manually. Now, they are looking for ways to enhance communication through automation while maintaining individuality in their member engagement.
Finally, member engagement itself is undergoing a change. Again, automation and technology are playing a significant role. And instead of being reactive and relying on claims and past reports to direct their engagement approach, payers are utilizing data and technology to create a new perspective, uniting claims data and the clinical viewpoint.
Furthermore, they are conducting predictive analytics and applying preventive medicine rather than merely reacting to the problem.
Because of these changing objectives, younger vendors are moving into position to guide the industry into better utilization and care management.
The older vendors –Medecision, Cognizant, ZeOmega–have a higher market presence and new consideration energy, the KLAS report acknowledged
But when looking at the data, it becomes clear that the younger vendors are poised to take over. The youngest vendors, HMS Essette and VirtualHealth, lead the way in the number of times that payers considered them and take second and third place in the rate of selection, or the number of times that they were selected out of the number of considerations.
Medecision and Cognizant also had the highest occurrence of replacement. While HMS Essette also was being replaced by one vendor, the number of times payers selected HMS Essette’s system far outweighed its replacements, which cannot be said for Medecision or Cognizant.
The KLAS researchers did acknowledge that these more nascent systems have not been on the market long enough to assess customer satisfaction.
The researchers were able to determine customer satisfaction for vendor VirtualHealth, landing the vendor with the highest user satisfaction rate among all vendors with sufficient data
The KLAS data indicates that the payer industry could be on the brink of a technological shift in utilization and care management. Whether these indicators come to fruition will depend largely on which vendors achieve the highest functionality.
As the healthcare industry shifts toward integrated, coordinated, value-based care, payers with a future-focused mindset will seek out innovative vendors that demonstrate high functionality and support a member-centered business model.
Date: August 30, 2019