Scott Polansky, Appian’s Industry Practice Lead for the Healthcare Payer Industry discusses digital transformation topics and trends impacting healthcare payers. Topics include customer behaviors, adapting an agile approach, the importance of a unified member view and accurate provider directories, as well as the current state of uncertainty amidst healthcare reform. Abby Jacobs serves as contributing host.

TRANSCRIPT:

Abby: Hello and welcome to the Appian Industry Outlook Podcast, where we take time to speak with Subject Matter Experts on digital transformation topics impacting their industries. I’m your host Abby Jacobs, a member of Appian’s digital marketing team and a self-proclaimed digital disruption evangelist.

Today, I’m joined by Scott Polansky, Appian’s Industry Practice Lead for the Healthcare Payer industry.

Thanks for joining us today, Scott!

Scott: Thanks for having me. It’s a pleasure to be here.

Abby: Before we get started could you tell us a bit about your background and your role at Appian.

Scott: I’m Appian’s Healthcare Payer Industry Practice Lead, where I help support the sales efforts around the country. Prior to Appian, I have 30 years of experience working for primarily Healthcare Insurers as well as doing some consulting business in a broad range of operational and strategic roles.

Abby: That’s quite an extensive background. I’m sure you’ve witnessed many changes in the healthcare industry over the years and how payers are changing the way they do business. What would you say are the biggest topics currently influencing customers behaviors for healthcare payers?

Scott: I think top of mind for customers is looking at greater flexibility and simplicity in product, benefit and network design. Consumers out there struggle with affordability. We called it the Affordable Care Act but it was really anything but in many instances.There’s also a tremendous lack of transparency around cost and quality, so those are the primary drivers. From the payer standpoint, they’re trying to figure out how they can better engage with their members to be able to drive better outcomes and quality of care.

Abby: From your experience, how are healthcare payers adapting to today’s digital economy?

Scott: It’s a spectrum out there. What we see is that those who are innovative and successful are adapting an agile approach to developing software and technology. They recognize that legacy systems do not provide the flexibility or speed to market so they are adopting new platforms to develop customized apps and integrate data from multiple disparate systems. Innovative payers are moving away from point solutions and towards enterprise platforms that enable the rapid development of customized solutions.

Abby: It goes without saying that adopting a customer-centric approach is essential for any organization in order to compete and deliver in today’s landscape. We’re witnessing a huge shift in what exactly that means and who exactly is a consumer across all industries. For healthcare payers, who are the consumers or stakeholders they need to keep happy and how are they able to do so in an agile way to meet growing expectations?

Scott: Payers have multiple stakeholders and they are trying to figure out how to simplify processes to create a better customer experience. It starts with the members who either come directly as individuals (retail) or through an employer. Often times a broker or consultant is involved and the plans need to meet their needs. Providers (facilities, physicians, medical professionals) are another critical stakeholder and the growth of value-based care will only intensify the need for cooperation and collaboration between providers and payers. Finally, the payer’s employees are critical stakeholders whose needs cannot be overlooked.

Abby: Now you spoke a lot about providers and recently we’ve been hearing more about how having a unified view of members and providers is critical, and the importance of maintaining accurate provider directories. What are the biggest risks and opportunities for healthcare payers around this topic?

Scott: I’m glad you asked that. As I travel around the country talking to our prospects and clients and speaking with industry professionals at conferences, that’s one of the number one topics out there and the risks are many. For provider directories, the risks are both financial and operational. The financial risks include potential fines from CMS and State regulators for not maintaining accurate directories; as well as more indirect costs due to membership losses (or lack of growth) because members are dissatisfied with their experiences. Additionally, providers might be less willing to contract with a payer if they’re not being represented accurately to members.

Operationally, there are huge inefficiencies and wasted resources because payers have not developed efficient processes to manage provider data. The challenges are not only in collecting accurate data from the providers, but also in managing processes to insure that the data is maintained among various systems such as claims, contracting, credentialing, and appeals and grievances.

The unified view of member is critical to be able to integrate clinical data from providers with financial data from the payers. The payers are in a unique position to do this as they are the hub for all the claims from multiple providers. If we’re going to achieve better outcomes the payers have to have that integrated or 360-degree view of members. Additionally, the continuing growth of population health initiatives and value-based contracting makes it imperative for payers to have a more integrated view of both members and providers.

Abby: Those are a lot of moving pieces and a lot of factors for healthcare payers to keep in mind as they look to digital transformation to improve operations and keep stakeholders happy. Now with everything going on in Washington right now around healthcare reform, I have to ask, how does this impact the way healthcare payers do business and the technologies and approaches they’re considering with their digital transformation approach? Could you speak a bit about this and what you’re witnessing in your experience?

Scott: The continuing uncertainty is causing many payers to pull out of government programs as they are concerned about regulations causing unsustainable rating and underwriting (e.g., high risk pools, lack of mandated coverage). Due to the uncertainty, many payers are pulling out of marketplaces and making decisions for today that will impact 2018 and 2019. The challenge for payers is that with their legacy systems they have very inflexible platforms that are prohibiting them from responding to these rapid changes. Payers will need an agile technology platform that will allow them to respond quickly to changes. If they continue to pursue complex off the shelf solutions, they will be just like everybody else and will not be able to create unique competitive advantages. Successful payers are working with these agile platforms to be able develop customized solutions to meet their unique needs.

Abby: There certainly are a lot of layers and organizations seem to be at different stages of their digital transformation strategy. What would you say is one critical first step required for all healthcare payers to start their digital transformation journeys?

Scott: I think the first thing is to define what digital transformation means to the organization. Some think it primarily means going mobile while others might think it means going paperless. The way I define digital transformation is using technology and software to allow you to develop competitive advantages in the marketplace. The other critical step there is healthcare payers need to recognize that their legacy systems are not allowing them to be competitive in the marketplace. By the time they develop their requirements and start building the software and end up with a solution the requirements are out of date and the regulations have already changed so again, it’s the importance of having that agile platform.

The other thing I would say is critical for success is moving to the cloud. I think a lot of organizations have been somewhat reluctant but we are seeing a growing trend towards moving to the cloud and that’s going to allow payers to be much more efficient in the future by allowing them to alleviate the burden of managing their technology platforms and instead allow them to focus on innovation and solutions.

Abby: There certainly are a lot of moving pieces for Healthcare Payers to consider. I know we covered a lot of territory today so thank you for taking the time to share with us and we look forward to catching up with you again in the future.

To learn more about Appian as a digital transformation platform for healthcare, you can visit appian.com/healthcare.