Implementing New Technology for Health Plans

Today's health plans operate under a wholesale business model in which the employer chooses what to spend, where to spend it, what the network is and who the providers are. Health plan products traditionally consist of a financing vehicle and a physician network. In a retail business model, however, consumers will drive the decision-making process, and they will demand more choices for their healthcare dollars. Members will expect their health plan to offer quasi-customized products that offer customizable options within a customer service, medical management and a provider network. This is similar to consumers having the ability to build a "customized" computer from a limited number of components.



Health plan product modularity will have a dramatic impact on claims adjudication and customer service because it will create a more complex infrastructure for accessing and assembling data to meet consumer requests. Therefore, plans will need to provide more information and decision-making tools, as well as multiple, self-service and assisted contact channels (such as web, e-mail, IVR and other media) to help consumers select and manage their product and payment options. Current health plan IT and customer service systems are not equipped to handle this transformation to a retail business model. Most organizations' legacy systems are so old and outdated they have difficulty getting the basics right, let alone handling a new, more sophisticated functionality.



In the future, products will drive health plans' operational capabilities of sales and distribution channels, pricing and risk management, customer care, care decision support, medical and network management, claims processing, and membership accounting—rather than operational capabilities driving products. Yet, moving from today's reactive, manually intensive business model to a proactive, information-driven one will require technical capabilities that are significantly evolved.