Prescription for a Healthier Tomorrow: Considerations for Health Insurance IT Modernization in Brazil ORACLE WHITE PAPER JULY 2014

Transcription

1 Prescription for a Healthier Tomorrow: Considerations for Health Insurance IT Modernization in Brazil ORACLE WHITE PAPER JULY 2014

2 Disclaimer The following is intended to outline our general product direction. It is intended for information purposes only, and may not be incorporated into any contract. It is not a commitment to deliver any material, code, or functionality, and should not be relied upon in making purchasing decisions. The development, release, and timing of any features or functionality described for Oracle s products remains at the sole discretion of Oracle. PRESCRIPTION FOR A HEALTHIER TOMORROW: CONSIDERATIONS FOR HEALTH INSURANCE IT MODERNIZATION IN BRAZIL

3 Table of Contents Executive Overview 2 Introduction 2 Keeping Pace with Rapid Growth 3 IT Modernization in Brazil 4 Get Agile 4 Amplify Business Intelligence IQ 5 Help Members Help Themselves 6 Real-World Success 6 VGZ Cuts 30% of Costs for Claims Processing and Policy Administration through Use of Health Insurance Technology 6 Conclusion 6 1 PRESCRIPTION FOR A HEALTHIER TOMORROW: CONSIDERATIONS FOR HEALTH INSURANCE IT MODERNIZATION IN BRAZIL

4 Executive Overview Brazil, the fifth most populous country in the world 1, has undergone significant political, economic, and demographic changes over the years, and today faces historic transformation with regard to its healthcare system. While Brazilians have free access to healthcare through a public system the Unified Health System or the Sistema Único de Saúde the private healthcare system is growing at a rapid pace. Healthcare payers which for the most part employ decades-old core technology have limited business process scalability in a fast growing market, and struggle to keep pace with change. By consolidating legacy systems onto a single health insurance-specific platform, payers can support core business processes and emerging opportunities in the private sector, while establishing critical flexibility in their IT infrastructure that increases visibility, reduces operational costs, and drives innovation within the business. Introduction In Brazil, healthcare is a birthright. Since the twentieth century, the Brazilian government has worked hard to establish healthcare as a universal, state-sponsored system financed through taxes at the federal, state, and municipal levels. Over the years, however, as Brazil has become one of the world s fastest growing large economies and populous countries, its public health option has become strained. As a result, individuals are increasingly seeking care in the private sector. Over the next few years, Brazil expects that more than 20 million additional individuals will purchase insurance through a private health plan, bringing the total number of participants in the private system to more than 75 million. This projected growth presents significant opportunity for private health plans, but are they ready? It is difficult at best for healthcare payers to capitalize on new opportunities with legacy IT systems that resist change. Custom development is a costly and cumbersome approach in a business where competitors change tactics overnight. Payers seek greater agility to address their specific business requirements and adapt in real time to ever-shifting market conditions. For this reason, Brazilian payers need flexibility as a central IT platform design component. They require applications that support core business processes in Brazil s increasingly blended public and private systems, in which people may choose a private health plan as a supplement to, or in lieu of, public insurance ultimately supporting business innovation and rapid growth. 1 The World Bank: 2 PRESCRIPTION FOR A HEALTHIER TOMORROW: CONSIDERATIONS FOR HEALTH INSURANCE IT MODERNIZATION IN BRAZIL

5 Keeping Pace with Rapid Growth Since the late twentieth century, the Brazilian constitution has ensured that all residents including foreign residents have access to healthcare. The populace can obtain this service from the Unified Health System, from private providers subsidized by the federal government, or from the private sector via private health plans or employers. Those who cannot afford to pay for healthcare in Brazil use the government s free public national health system, and pay nothing for doctors fees, lab fees, hospitalization, surgery, or even prescription drugs. For the most part, the Unified Health System has been a success. The country realized an infant mortality rate of approximately 13 per 1,000 live births, reduced from 27 in 2000; a maternity mortality rate cut in half since 1990; and an increase in average life expectancy from 66 to 74 2 since However, Brazil s budding economy, up-and-coming middle class, and progressive policies toward managed care make it a high-growth market, and the public system is struggling to keep pace. The private system, by and large, operates much more efficiently, with shorter waits and quality care. As the population becomes wealthier as the result of economic growth, more Brazilians approximately 55 million individuals totaling a quarter of the population are choosing to enter the private healthcare system. The influx into the private healthcare system opens significant opportunity for Brazil s health plans. It also presents several challenges. First, health insurance is inherently more complex than life and property and casualty (P&C) offerings. Healthcare payers must deal with regulatory and contractual complexities that are unique to the sector, such as waiting period requirements, co-pays, and the negotiation of in-network versus out-of-network agreements. They must also have the scalability required to process a much higher volume of claims than in life and P&C lines of business. Healthcare payers can expect to handle dozens of claims per member, adding up to tens of millions of claims annually, and they must do so rapidly and cost effectively. Processing these large volumes of transactions can place tremendous strains on payers who continue to adhere to manually intensive systems. And, therein, lays the problem. Many of Brazil s healthcare payers simply are not equipped with modern technology needed to keep pace with the private system growth. So, where do they go from here? What is the prescription for success? 2 Olga Khazan, What the U.S. Can Learn From Brazil's Healthcare Mess, The Atlantic, May 8, 2014, 3 PRESCRIPTION FOR A HEALTHIER TOMORROW: CONSIDERATIONS FOR HEALTH INSURANCE IT MODERNIZATION IN BRAZIL

6 IT Modernization in Brazil The private healthcare system in Brazil is projected to grow by 20 million members to 75 million in the coming years. Not surprisingly, many payers want a piece of the pie. But, with aging technology and cumbersome manual processes, taking on new members is virtually impossible. Payers cannot afford to sit idly on the sidelines while opposing teams battle for victory. Instead, they will be well served in the short- and long-term by moving forward with their own game plans for success in a new era of healthcare finance and coverage. There are several strategies that payers can put into action today that will serve them well now and in the future regardless of how the Brazilian health plan market continues to evolve. Get Agile The need for unprecedented agility increasingly defines Brazil s health plan market. As stated, many payers in Brazil are riddled with error-prone manual processes and disparate legacy systems that are not scalable or flexible enough to support innovation or growth. To continue to compete profitably in an unpredictable market, payers need an adaptive IT foundation that provides the flexibility to respond to a changing climate. Today s payers need the ability to quickly configure and launch new products to meet shifting market conditions and capitalize on new opportunities. This requirement is expected to intensify as new populations with unique needs enter the private health plan market. Rules-based systems built on an open architecture can facilitate integration between internal systems to enable rapid new product introduction. For example, a rules-based system can help payers automate a manually-intensive surgical glove approval process (surgical departments typically have limits on the number of gloves they can use daily) saving them time and money. 4 PRESCRIPTION FOR A HEALTHIER TOMORROW: CONSIDERATIONS FOR HEALTH INSURANCE IT MODERNIZATION IN BRAZIL

7 With Oracle Health Insurance Back Office, we have reduced operational costs related to claims processing and policy administration by 30%. Adriaan Baan, Head of Claims Department, VGZ Adaptive back-office systems (including rating, underwriting, and claims processing solutions) are also increasingly important for payers as they work to automate manual processes and meet changing regulatory and customer needs. For example, to meet consumers requirements for information and transactions on demand, payers are working to accelerate quoting, underwriting, and policy issuance processes. Payers also seek to provide more convenient channels for interacting with policy holders throughout the entire customer lifecycle from quote, through claims, to renewal. To achieve this goal, they require open, easy-to-integrate applications that offer a single source of truth across all channels. Amplify Business Intelligence IQ Business intelligence (BI) and analytics are more and more vital on many levels, acting as an essential tool in determining profitability; assessing risk when rating and issuing policies; evaluating provider and treatment effectiveness; analyzing claims; identifying possible provider and/or subscriber fraud; and analyzing market trends to help develop innovative new products. BI and analytics will become even more vital as payers enter unknown territories and serve expanded populations. The ability to assess profitability and drill down into data for insight into specific products, markets, populations, and providers will be essential to continued growth. As important, BI can play a vital role in evaluating various provider and treatment course effectiveness today and into the future. Payers can also support automated claims process by applying BI to claims data, then using that intelligence to create and continually refine business rules to drive automated processing. Medical fraud is a potential problem area as the volume of claims expands, with 20 million Brazilians securing new insurance coverage through private health plans in the coming years. Sophisticated analytics are vital in helping payers to rapidly identify patterns that may indicate fraudulent activity and enable them to effectively target cases for further investigation. Analytics and BI solutions integrate information from multiple sources, thereby improving fraud detection s efficiency and effectiveness, and ultimately reducing operational costs. 5 PRESCRIPTION FOR A HEALTHIER TOMORROW: CONSIDERATIONS FOR HEALTH INSURANCE IT MODERNIZATION IN BRAZIL

8 Help Members Help Themselves Self-service enables healthcare payers to provide more convenient service at a lower cost yielding benefits today and tomorrow as volumes increase. Payers can help members to locate providers, pay premiums online, and identify benefits/eligibility for treatments. Self-service web portals and mobile applications can play an important role of putting this vital information directly into the hands of consumers. Payers can also use self-service to deliver new convenience and add value to providers and plan sponsors, while lowering call center and support costs. For example, providers can have the ability to track and inquire about payments online, as opposed to having to call the payer. Real-World Success While Brazilian healthcare payers challenges are complex as they seek opportunities in a growing market, they are not unique. Oracle Health Insurance is focused on helping healthcare payers around the world with their modernization challenges by providing applications that support payers business processes, enabling them to implement changes and provide consumers with tailor-made products while using uniform administrative processing. The Oracle Health Insurance suite of applications have proven their scalability at customers with sizes ranging from 100,000 to 4,200,000 members (with approximately 10 million product enrollments) in a single instance. In addition, Oracle offers engineered systems or hardware, software, and storage tuned to address specific health plan challenges including high availability, performance, and scalability. For example, VGZ, a nonprofit health insurer, plays an active role in organizing smarter healthcare in the Netherlands. With more than 4.1 million policyholders and 187 million claims processed each year, it is the secondlargest healthcare organization in the country. The company uses Oracle Health Insurance Back Office to meet its goals of providing affordable healthcare that is based on qualitative medical services, excellent customer service, and superior operational efficiency. VGZ Cuts 30% of Costs for Claims Processing and Policy Administration through Use of Health Insurance Technology VGZ wanted to consolidate three of its management applications acquired through the merger of three organizations into a single health-insurance-specific platform to enable the company to respond rapidly to frequent and complex changes in Dutch healthcare insurance laws. In addition, it wanted to improve customer service by offering self-service functionality, cut IT costs for management and support, as well as gain an advantage in a highly competitive sector. The company s Oracle Health Insurance Back Office deployment improved its ability to support customer service, Internet sales, provider contracts, policy administration, claims processing, pre-authorizations, and billing functions. With the solution, VGZ reduced operational costs by 30%, thanks to straight-through processing of claims to achieve a yearly savings of US$10 million in IT expenses and US$24 million in operational costs for claims. Conclusion With a rapidly expanding economy and population, the Brazilian healthcare marketplace holds tremendous opportunities for payers to prosper. For payers, success is not assured due to their challenges. They must adopt a modern, IT infrastructure that brings critical flexibility and agility to drive innovation within the business. In doing so, they will be well prepared to overcome the challenges of the future while reaping important benefits today. 6 PRESCRIPTION FOR A HEALTHIER TOMORROW: CONSIDERATIONS FOR HEALTH INSURANCE IT MODERNIZATION IN BRAZIL

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