Commentary & Analysis
The Managed Care Industry: A Challenge and an Opportunity
By Ellen M.
By WhatTheyThink Staff
Published: March 1, 2004
By Ellen M. Traberman March 1, 2004 - Last month, PathForward's Rob Onorato wrote about opportunities for graphic arts service providers in the manufacturing industry. As the next chapter in our continuing series, I will be sharing with you insight relative to Managed Care, an industry I have been involved with the past 15 years. What is Managed Care? According to MCOL (www.mcol.com), an online portal focused on helping health professionals position themselves for a new kind of health care in the 21st Century, managed care is defined as “a complex system that involves the active coordination of, and the arrangement for, the provision of health services and coverage of health benefits.” The most common types of Managed Care Organizations ( MCOs ) include Health Maintenance Organizations ( HMOs ), Preferred Provider Organizations ( PPOs ) and Exclusive Provider Organizations (EPOs .) Managed care generally involves three key components: oversight of the medical care given; contractual relationships and organization of the providers giving care; and the covered benefits tied to managed care rules. In contrast, traditional health plans take a more passive approach, generally paying for a percentage of the cost of health services at the provider's usual charges after an agreed-upon deductible is met. In a traditional health plan, the patient can choose any physician, and physicians can choose to order whatever services they feel are necessary without the oversight inherent in the managed care approach. Industry Trends Managed Care—and in fact the health industry as a whole—has been faced with an increasing set of challenges in recent years. Hardly a day goes by without a news story about the skyrocketing costs of U.S. health care and the impact it has on employers and families alike. At the same time, the government continues to impose stiffer guidelines and regulations on this already heavily regulated industry, in an attempt to control costs, improve quality and assure protection of patient rights and privacy. As I look at the Managed Care industry, three key trends are top of mind for these organizations. The need to comply with multiple - and sometimes conflicting - regulations, affects the ability of these organizations to change the way they communicate with their members Regulatory compliance and increased focus on the security and privacy of personal information. Central to this is HIPAA, the Health Insurance Portability and Accountability Act of 1996. The purpose of HIPAA is to “amend the Internal Revenue Code of 1986 to improve portability and continuity of health insurance coverage in the group and individual markets, to combat waste, fraud, and abuse in health insurance and health care delivery, to promote the use of medical savings accounts, to improve access to long-term care services and coverage, to simplify the administration of health insurance, and for other purposes.” For the health care organizations that have scrambled to comply with HIPAA, I am sure it feels like anything but simplification at this point. You probably have noticed the acknowledgement of privacy policies that you must sign the first time you visit your health care provider or fill a prescription subsequent to their implementation of practices designed to comply with the Act. While this is the most obvious sign of HIPAA to the patient, behind the scenes providers have had to examine and redesign a multitude of business processes, almost all of which are document-related. To add to the complexity, providers must not only comply with the Federal regulations, but they must adhere to state regulations as well—and each state has its own set of regulations. Managed Care providers frequently do business in multiple states, and some even have presence in all 50 states. As you can imagine, the need to comply with multiple—and sometimes conflicting—regulations, affects the ability of these organizations to change the way they communicate with their members while still maintaining compliance with the law in the states in which they operate. For more information on HIPAA, visit www.hipaa.org , a portal site that provides access to a wide range of resources. The second major focus of the industry is a continued emphasis on retention of members . In general, managed care organizations manage their expenses on a per-member-per-month basis. This means that they closely monitor their administrative costs with a view toward more efficiently communicating with members at a reduced cost, leading to widespread adoption of Web self service for many documents and communications that were previously distributed via mail. This includes explanations of benefits (EOBs), contracts and other paperwork that most of us stuff into a drawer. In many cases, federal and state regulations interpret materials posted to the Web for self-service as “delivered.” And for members who routinely use the Web, information is more accessible than it was in the past when it was shuffled into a pile of papers. Finally, as with many industries, there is a significant amount of consolidation underway, with acquisition and merger activity starting to heat up again as the economy rebounds. When companies are combined as a result of a merger or acquisition, not only do they need to integrate disparate systems, but they must also rationalize their document-related business processes, settling on a consolidated set of forms, reports, customer communications, etc. This is an ideal time to re-examine these various, and oftentimes related, supply chains and business processes to determine how and whether they can be optimized for increased efficiency. Document Processing a Common Thread One of the most common obstacles I find to implementation of more effective member communications is the condition of their databases The common thread that runs through these challenges facing the managed care industry is the need to more efficiently manage information—and documents—across the enterprise, and to leverage that information to more effectively attract new members and better communicate with and retain existing members, while remaining in compliance with Federal and state regulations. This is not a trivial task, and the industry has a long way to go. As I visit various provider organizations, one of the most common obstacles I find to implementation of more effective member communications is the condition of their databases. Even though providers have significant member information, they have difficulty keeping information current, particularly as members move and change jobs. Most are dealing with legacy systems that have been patched up over the years in modernization efforts. Following a merger or acquisition, disparate systems must be integrated. And many managed care providers have transitioned from old-line insurance organizations and simply are not ready to implement advanced CRM solutions. This is further complicated by the need to be very, very careful with how personal information is utilized for member communications and marketing efforts, both from the perspective of regulatory compliance and the perception relative to privacy issues of the member receiving these personalized communications. There is also still a significant amount of paper-based fulfillment activity within the industry despite the trend to Web self-service. Some providers have implemented an integrated “evidence of coverage” package that combines a number of communications, including insurance cards, into a concise booklet. But many are still sending multiple new member communications that are inconvenient for the member and expensive for the provider. How Can We Help? For those of us with document processing expertise, the Managed Care industry represents both a challenge and an opportunity. First and foremost, these organizations prefer to deal with providers who understand the industry and their specific challenges and needs. This means that you must invest time in gaining an adequate industry knowledge level before you make even the first call on a managed care organization. You must invest time in gaining an adequate industry knowledge level before you make even the first call on a managed care organization At PathForward, we have focused our efforts on helping these organizations find ways to reduce the amount they spend on print with a combination of migration to electronic documents that can be delivered through Web self-service and an analysis of the effectiveness of the documents they are using. Our PrintConcierge approach as described by Rob Onorato last month also resonates with this industry. Many of these organizations have investments in in-plant operations and are always looking at options relative to insourcing versus outsourcing. The PrintConcierge™ model allows them to benchmark their cost of delivering services internally against the market at large and make necessary adjustments on an ongoing basis. Making Managed Care more efficient and effective will benefit all of us. We all have a vested interest in controlling the cost of health care. And we all certainly care about the quality of health care—especially as it relates to us individually and to our families. By working with these organizations to help them leverage technology to improve workflows throughout the entire document-related supply chain, we can make a difference.