Health insurance gets no love.
It's a necessity to keep us all flourishing, yet insurance is consistently ranked at the bottom of customer satisfaction. Then you have all the competing forces tugging at you daily and the blank stares you get when discussing your work at parties. It can be a slog.
I feel your pain. I spent years at a third-party administrator, insurance software company, and one of the largest US pharmacy benefit managers. So much of that angst comes from managing multiple stakeholders with competing priorities, all while trying to create a thriving business.
Managing Market Pressures
Working in health insurance requires managing competing market pressures:
- Members want to find care as easily as possible and understand what they have to pay for and why
- Government and non-government employers want to keep medical cost trends down while reducing complaints from those same employees
- Providers want to interact with you as little as possible but also want to be paid as much and as quickly as possible
- Competitors want to chip away at your business by differentiating or managing risk pools better
- Shareholders want to maximize profits by either increasing premiums or reducing costs
Individually, each of these stakeholders is manageable. But when members want to find more services AND providers give you inaccurate data AND your shareholders want to keep costs down…it’s a tricky balancing act.
What Are Common Pain Points?
The good news is that solutions are out there, especially if you approach this with a product mindset. That starts with understanding the root cause of these pain points and how they're interrelated, then finding the right tools to address them. Here are common themes I've discovered working inside payers and with our clients:
• Finding and directing care
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- Members may struggle to find doctors because the underlying data is poor or disconnected. When looking across the data management lifecycle, this can stem from poor data ingestion from providers or health systems, manual handoffs between different departments, or data systems that don't talk with one another. And some helpful decision-making data (e.g., cost estimates, Medicare star ratings) might be housed across different systems that don’t surface at the right times.
• Claims processing
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- When looking at the claims processing lifecycle, things can break down if you can't remit payments due to the same data inconsistencies between adjudication and billing platforms. Beyond that, less common cases like appeals and investigations require rigid controls and management to prevent them from getting lost or delayed.
• Setting client expectations
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- Employers, especially self-insured employers, are often unhappy when their members aren't getting the care that they're promised, or they see the medical cost trend move in the wrong direction. This can result from either too much plan customization (which is difficult for your operational teams to execute consistently) or a lack of transparency into how you're managing medical utilization.
• Differentiation
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- Some markets and products are in a zero-sum game where every carrier is fighting for the same lives. This leads to recycling ideas, incentives, and programs that make one payer indistinguishable from another. Then there’s a race to the bottom on pricing or market consolidation to take advantage of scale rather than focusing on the tough work of innovation that will make healthcare better.
4 Ways To Alleviate These Pain Points (and keep your stakeholders happy)
What can be done? With so many pressures and pain points to address, it’s tempting to hire new people to tackle these problems - and sometimes that does help. However, my experience at various health insurance entities points to four parallel paths that can reduce the burden payer teams feel:
1. Transitioning to modern data management systems
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- Modern systems are critical to allow more consistency and better workflows to handle this overwhelming amount of data. Credentialing companies and provider data management companies (like Orderly Health) can build seamless integrations to claim management systems to reduce errors and remediate data silos
2. Creating, enforcing, and revisiting internal standard operating procedures
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- SOPs, key performance indicators, and operational data monitoring ensure a consistent experience for your teams based on industry best practices. You’ll support your teams by reducing ambiguity, creating clear benchmarks, and catching errors, like late payments or stalled claims before they become a problem with members or providers.
3. Standardized plan design and reporting
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- Plan designs and contracts with limited variability reduce employer customization, creating repeatable processes and better expectations. In addition, empowering your customer success teams with comprehensive data dashboards and reporting will quantify your value to clients and identify meaningful changes in trend and utilization to let you act like a true partner.
4. Carving out resources for innovation teams
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- Funding innovation teams and consistently running experiments can unleash new, differentiated ideas. By celebrating the calculated risks from these teams, you create a culture of experimentation and ensure the organization is not over-indexed on pure operational execution. This will keep your company competitive in an increasingly crowded market.
Conclusion
These solutions aren't just about tackling the tough stuff in the world of health insurance. They're also about keeping all your stakeholders smiling. By bringing in modern data management systems, sticking to best practices, streamlining plan designs, and giving innovation the green light, you're not just making your job easier—you're driving positive change and fostering satisfaction across the board. Because when members, employers, providers, and shareholders are all feeling good about things, that's when you know you're hitting the mark in healthcare.
Implementing these solutions can be tricky to tackle on your own, but you can supercharge your organization by finding a partner who understands your unique situation. Orderly Health is committed to helping payers modernize their data systems. Connect with us today to learn more about on how we’ve brought the love back to health insurance!
About Our Guest Author:
Louis Levine is VP of Product at Orderly Health. He’s a product and healthcare leader who’s passionate about problem solving and improving our world using data, technology, and engagement solutions. Outside of Orderly, Louis can be found practicing yoga, volunteering, developing new recipes, or seeking new adventures in Denver or abroad.
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