REALIZING THE POTENTIAL OF BPM IN HEALTHCARE

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1 REALIZING THE POTENTIAL OF BPM IN HEALTHCARE Gregory Anderson Co-Founder & Principal Top Tier Consulting THE NEW QUESTION: IS IT TIME FOR HEALTHCARE TO FULLY EMBRACE BUSINESS PROCESS MANAGEMENT (BPM)? In the past, our healthcare industry has not utilized BPM to its full potential. Health plans have embraced BPM mainly for processes such as sales force automation and call center implementations. However, a broader vision for BPM is the end-toend management of consumer-centric processes. Today s BPM tools can be utilized to modernize legacy systems, achieve operational excellence, and create a seamless consumer experience. August 2013 Healthcare reform is one of the major factors driving recent activity around BPM and illuminating the value of its solutions. For health plans, reform places a great deal of focus on Health Benefit Exchanges and on individual and small group lines of business. Additionally, many health plans and their providers are deeply committed to 5-STAR initiatives for Medicare Advantage Plans. At the same time, the advent of Medicaid expansion creates the opportunity to serve a growing population of dual eligibles, while exposing a number of integration and operating issues. Going forward, BPM will play a key role in our industry. BPM will assist us in creating a consumer experience that differentiates a health plan or provider and satisfies the engaged, accountable health consumer. How will this be accomplished? Through the establishment of a set of interactions on multiple channels, the consumer will gain access to healthcare applications that are secure, interactive, and easy to use. The health consumers of the future will expect to access their information on-demand. They will switch health plans if administrative and operational excellence is lacking, or if greater value is offered by other plans or providers. BPM will highlight your competitve differentiators to attract and retain members and patients. Point of View v4 1

2 WHY RETHINK NOW? THE NEED FOR INTEGRATION HAS NEVER BEEN GREATER A number of hurdles have hindered the adoption of BPM, particularly the cost of the platforms. Today, BPM is more affordable and even user-friendly. We now see BPM tools that involve Consumer Experience and enable business users rather than strictly IT users to participate in requirements definition, process re-design, and business integration visioning. focus on the accountable health consumer. While both of these trends have been identified in the past, there is a renewed focus on the individual whether we call it the accountable health consumer, consumer experience, or patient engagement. Healthcare Reform Many initiatives of healthcare reform such as those from the Center for Medicare and Medicaid Services (CMS) and Accountable Care Organizations (ACOs) are incenting payers and providers to work together. BPM enables payers and providers to integrate and automate processes across organizations. This integration supports management and operational reporting between ACO partners and assists them in achieving operating excellence. Regulatory Compliance With some of the greatest evolutionary changes in our industry about to be implemented, the attention to regulatory compliance is higher than ever. A major driver is the increased number of beneficiaries that will be eligible to participate in governmentsponsored health plans at the Federal and State levels. New processes, workflows, and business rules will be required to properly administer medical services and benefits to this population. Healthcare Reform is forcing two major trends: first, the need for better integration between payers and providers, and second, an even stronger Integration of Silos For years, siloed legacy systems have hindered integration in the healthcare system. BPM can serve as an application development and integration platform. These platforms create end-to-end, automated business processes layered on top of multiple vertical transaction processing systems. This allows separate organizations to function as a cohesive unit. Vendor Innovation BPM platforms are more cost-effective, adaptable, and flexible, allowing for process layers and rules to be externalized from legacy systems and easily maintained as a business grows. BPM manages steady state and change within processes and rule sets. It now includes predictive and analytical tools, which will assist customer service and other business functions to create more targeted and relevant interactions for their members and/or patients. 2

3 WHAT TO RETHINK? PRIORITIZING YOUR PROCESSES FOR BPM AUTOMATION While continuing to utilize BPM to focus on sales force automation, customer service, and call centers, look for the processes that are most crucial for your healthcare business in the next three years. Prioritize based on three categories: consumer experience, payer-provider integration, and operational excellence. Consumer Experience Apply BPM to enhance the consumer experience. Enable the accountable health consumer by designing consumer-centric interactions that can integrate and connect the processes of both the health plan and provider. Examples are: Web Portals Care Management Connected Care mhealth Applications Operational Excellence Use BPM to leverage legacy transaction processing systems; add a layer of workflow and business rules around them in areas such as: Open Enrollment Processing Enrollment & Billing Claims Intake & Routing Claims Repair & Inventory Tracking Several healthcare organizations are undertaking major projects with these applications today. BPM is the way to make end-to-end processes a reality. With automated workflow and business rules managed together, an organization can extend beyond internal and external boundaries without replacing legacy systems. Health Plan & Provider Integration Design solutions that create a seamless, end-to-end process between payers and providers to collaborate, exchange information, and address problems in areas such as: Contracting for Medical Services Care Management Grievances & Appeals 3

4 HOW TO RETHINK? ASSESS WHERE YOU ARE WITH BPM Here are seven actions that you can take to assess where you are and where you should go with BPM. 1. BPM Requirements The first step is to understand what you need BPM to do and the value it will provide to your organization. Do you need all the capabilities of a fully integrated BPM platform, or is imaging, work distribution, and workflow management enough? Is there a need to externalize business rules from legacy applications, which requires a business rules engine? 4. Opportunity Areas Identify and document the areas where the application of BPM can satisfy a strategic business need in the next three years. Define the opportunities, build business cases, and determine the level of effort, taking into account your gap analysis and timing. 5. BPM Partner Selection Assess your current BPM vendor and determine if you need to make a change. Actions 2 and 3 will give you insight into this question. 6. BPM Plan & Program 2. Process Automation Assessment Next, make an honest assessment of process automation in your organization. Ask yourself key questions: Have you piloted BPM tools? How are they working? Is there more demand for workflow automation? How is your relationship with your current vendor? How many people are trained to use the BPM toolset within your organization? 3. Gap Analysis After defining requirements and assessing your current BPM efforts, complete a gap analysis. Analyze how well requirements are being met, define realistic targets for where you want to be, and then identify and quantify the gaps. Next, create a Process Automation Plan and Program. Obviously, this will require both a capital and a human capital investment. Plan for a three year term. Prioritize the process automation projects to be funded and completed. 7. BPM Center of Excellence (COE) Once successful BPM projects are completed, demand from other business users will skyrocket. People in your organization, who have become experts in the tool, will advocate the benefits of process automation. To support the growing demand, standards and controls must be defined for the numerous BPM efforts that will materialize very quickly. Ultimately, the COE becomes a training and resource center for BPM throughout your organization. 4

5 THE NEW END GAME: CONSUMER EXPERIENCE PROCESSES So, where is all of this heading? When comparing healthcare to the financial services industry, we have a lot of catch up to do in the process automation space. However, over the next two years, healthcare reform and regulation will accelerate our adoption of BPM. Beyond 2015, where will our BPM investments take us? They will automate Consumer Experience Processes (CXPs). These processes emphasize the consumer rather than health plan or provider transactions and workflow as the focus of the design. Consider this figure. Consumer 1 3 The deeper adoption of BPM in healthcare today will lead to the Consumer Experience of tomorrow. Designing CXPs will demand a new level of integration between health plans, providers, and consumers that doesn t exist today. BPM will enable this integration and will allow the consumer regardless of channel, business segment, or population to be placed at the center of future state process design. Consumer Experience Processes are key elements for the future of healthcare. 2 4 Health Plan Existing processes must also be redesigned to place the member or patient at the center of traditional consumer interactions (lines 1 and 2) with a health plan or provider. Provider The gray lines illustrate today s siloed healthcare relationships and processes: 1. Consumer to Health Plan 2. Consumer to Provider 3. Health Plan to Provider The green line (4) represents a fourth set of required CXPs that place the consumer along the continuum of service for engagement with processes shared by the health plan and provider. To schedule a personal strategy briefing on this topic, Gregory Anderson Point of View Copyright Top Tier Consulting All rights reserved. 5

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