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SAPPOV: Healthcare payers – recasting the mold

Walt Ellenberger, MHA, Senior Director, Strategic Alliance, SAP Healthcare and Regulated Industries talks about SAP solutions for the Payer market as US healthcare insurance is undergoing dramatic change as it switches to a consumer focused accountable care model and Payers are confronted with redefining their value and managing entirely new types of relationships with their customers. How will Payers compete in this new consumer focused market?


As the US Healthcare industry undergoes dramatic change, Payers are suddenly faced with redefining their value and managing entirely new types of relationships with their customers, to avoid being commoditized in the emerging world of accountable care. How can they survive?

Look at the transformation the US healthcare market is going through and one key fact emerges: it’s much cheaper to keep people healthy than it is to manage them when they’re sick. It’s a responsibility the whole United States has to face, in terms of performance transparency, accountability and alignment of incentives in order to affect real change. Payment reform and consumer-directed healthcare are at the center of value-based accountable care. Payment for healthcare services is becoming more proactive and performance-based rather than reactive and transaction-based. Employers, faced with rising healthcare costs, are shifting out-of-pocket costs for routine care to their employees or simply passing responsibility entirely over to the government under the Affordable Care Act.

It’s an awkward period of transition. Personally, I believe it will be a huge wake-up call to the US population in general who have been sheltered from the real cost of healthcare choice and fragmented services. But with change comes opportunity. Personal healthcare accountability and financial responsibility
gives you and I as consumers buying power. With it we can put pressure on providers and payers of healthcare to be more efficient and outcome-driven. Our
“retail-like” expectations for simplicity, convenience, self service and value will ultimately change the rules of engagement in a healthcare world that most
people would agree is nowhere near meeting these needs.

Payers, ingrained in a business-to-business model, need to redefine their image, brand and values to compete in a consumer-facing arena. They risk being commoditized or taken out of the equation by companies becoming self insured and care delivery organizations that are now able to deal directly with employers, patients and consumers. Their focus needs to be on two key areas: care coordination and personalized engagement.

I can speak from personal experience regarding the need for care coordination. Not long ago, my father had to have surgery. The procedure went well. We had faultless hospital service and support. But post-discharge at home was a different ball game. Dad had an adverse drug complication resulting from conflicting prescription orders by his cardiologist and urologist. Having discovered this, I had to take time off work to liaise between the specialists and his primary care physician. What the process lacked was care-coordination tools to avoid conflicting orders and to communicate with different healthcare providers. An effective care coordination program will always be cheaper than a hospital readmission and a far better experience for the patient.

On the engagement side, I am an active 55-year-old guy who actively works at being healthy. Bluetooth-enabled devices such as my Fitbit mean I am a walking personal health database, monitoring daily activities against self-imposed goals. If my health insurer were to integrate and analyze this self reported data with utilization and clinical data, they could provide me personal insight on actual ways to maintain a healthy and productive life. That would be something of real value. If I was offered a health plan that would better engage and integrate me into the prevention and care coordination process, I’d only have one question: ‘Where do I sign?’

As consumers, we are already becoming more empowered and data-enabled, monitoring, informing and managing our own health and well being. Coalescing these tools and data streams as they emerge is key to success in the emerging consumer-directed health care market. What SAP can do is enable the enablers. Using proven technology and best practices in engagement and real-time business processing for the consumer-focused retail and gaming space, payers can position themselves to be a critical part of where healthcare is going, rather than where it has been.   

Towards a personalized service, three opportunities for Payers:

  1. Transform engagement and motivate consumers for personal health
  2. Proactively manage patients needing real time access to data and analysis
  3. Leverage traditional CRM best practice for the health retail consumer

To learn more about we can help you with your business challenges please have a look at SAP’s Solution Explorer for the Healthcare Industry.

What do you think about the issues discussed here? Continue the conversation in the comments below and on Twitter @SAP_healthcare

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