Scott Sbihli is senior vice president and head of product at HealthRules Payor, a modern administrative platform for health plans offered by Burlington, Mass.-based HealthEdge. He sat down with Becker's to discuss how payers can leverage new technologies and regulations to improve members' experiences through smarter medical and financial decisions.
HealthRules covers all core workflows of a health plan, including enrollment, billing, financials and claims adjudication through modern architecture and contract translation.
Question: How can modern administrative platforms help health plans better arrange their contracts with providers compared to more traditional platforms?
Scott Sbihli: If you look at value-based care, the variety and types of contracts that can be constructed are all over the board. It's really whatever the providers and the payers come up with from a risk standpoint. Being able to encode those contracts is really important. There's one piece about how to take a contract and translate it into something that's digital. The second piece is, how do I measure performance against those contracts to see if the providers are actually performing? Then you have the reporting, and then the payments — whether they're bonuses or not — against that. With a modern platform, you can take these contracts, with English-based rules and if the agreement is based on wellness programs or if it's capitation, and convert them into HealthRules language. Then it's captured and all the data is stored there and can be reported against to see if there's actual performance against those types of contracts.
Q: How do you believe the claims processing experience can be improved between payers and providers?
SS: Probably the biggest one, and the big push for us, is around digital — making a platform that is digital and real time and creates experiences that are very consumer-like. One of the things that we talk to our customers about is that there's an expectation by the members, and the providers, that there's no latency. They want an experience that's like Amazon, or like interacting with Starbucks — it's fast, it's simple and it can be done on a mobile device. The idea of seeing a physician on day one, but not seeing an explanation of benefits until several days later — that's not the experience that the members and providers want.
When we think about where we're taking not only HealthRules, but all the platforms at our company, we're creating capabilities through building acquisition or partnership that allows for creating the experiences that are real time, and that it combines both the care side of it and the claims side of it. If you're a provider, you want access to your boss. You also want to know what you're getting paid, but you would also like to know the status of your patients, whether that's delivered through a portal or web application.
The same thing is true on the member side, where a lot of digital care and digital member management is done, and more care management, education, assessments and [Internet of Things]. Then we want to combine that with experiences that include payments, advanced explanation of benefits, transparency, coverage and all these things that are being required as an expectation of the members.
Q: As the industry continues to move toward more value-based care systems and their respective methods of payment, trust and transparency between health systems and insurers will be key. How can better transparency and sharing of information and data be more incentivized?
SS: From a data collection standpoint, HealthRules is claims, payment integrity, care management and member management — we cover a very broad range of data that would be applicable to the payers and the providers.
The second piece is, how do you support that in terms of access? Historically, the old way of doing it was batch transactions and electronic data interchange. Now there are new standards like fast healthcare interoperability resources and real-time application programming interfaces giving access. We're looking at methods like analogs in other industries where you create, almost like a hub, what allows for third parties to connect in to have compatibility. If the payer wants to share information, we would allow access through these real time APIs.
Then you obviously have the government that's pushing for standards. In order to do value-based care, you have to have a claims history. If you don't have that continuity of who the member is, it's more difficult to create value-based care contracts and track those outcomes. We're embracing what customers do today and showing them what's possible with all kinds of new technologies for transparency.
Q: What type of trends are you seeing in value-based care?
SS: One of the things our customers are asking is, what are our other customers doing in value-based care? I think they're struggling a bit with where they should be experimenting. That was something I saw prior to the pandemic.
The other thing I would say is, we have to have flexibility in the system and supporting them — we can do capitation, prospective payments, episodes of care, bundled payments and tracking bonuses for a fee-for-service. To date, as our customers have been experimenting in these different areas, our system has been able to manage. I think where we want to go next is continuing to support our customers in being able to do the full tracking and sharing of that information, whether it's through portals to see if they achieved the outcome for the member.
Q: What regulatory shifts on this topic do you foresee coming down the pipeline and how can health plans make themselves more adaptable?
SS: I joined HealthEdge about four years ago, and the level of regulatory change has increased more in the past 18 to 24 months than in probably the last five years before that. The biggest change falls into digital transparency. I think our customers are looking at it as a cost that they have to bear — to be able to provide this data that is interoperable and eventually they'll have to transmit the history to another health plan. Transparency and coverage and the price calculators are causing them to have to put all this infrastructure in place. I think there's a ton of opportunity, because that same data can be used to create services for your customer. They can come in and ask a simple question through a mobile app, for example. How do you translate layman's terms into a set of diagnoses and procedures where you can wrap it up and say, here's where you can go and here are the different prices and outcomes that are there. If your basic tenet is, I provide insurance for recovery, you have to differentiate yourself. Creating a better consumer experience is really important. I think those regulatory trends, if we look at them in the right way, are going to create opportunities for some of the health plans to differentiate themselves.
Q: You mentioned applying new technology to current problems. What are you doing in regard to that?
SS: We have a data science team and we are looking at machine learning, but I'm a pragmatist about machine learning. I think that the hype cycle has gone through, and I do think it can be applied to very targeted problems. One example of where our teams are experimenting and actually making a fair amount of progress is auto adjudication rates. We're applying machine learning to what humans are doing on our customer sites, and we believe we've worked close to having some ways of improving auto adjudication, which is real dollars to the health plan using artificial intelligence.
Another area we're investigating is member churn. How do you identify the patterns that might suggest that somebody's getting ready to leave? How much do you intervene? It all starts with having a hypothesis and some data and creating models, and the models will tell you if there's something there.
Q: Final thoughts?
SS: A lot of health plans are modernizing, and they're making decisions on how they compete and support their members and providers in the future. I think between regulation and modern technology, they have this opportunity to create radically different experiences — transparency and real time — that will allow people to make better clinical decisions and financial decisions. You could know from your mobile app, through an advanced explanation of benefits, what something's going to cost, right there in English terms. That's what's exciting for me — not if you can support what the industry is doing today, but where they have to go based on the market trends.