PAYOR DATA LAKE by Shantanu Baruah

Transcription

1 PAYOR DATA LAKE by Shantanu Baruah WHITEPAPER SEPTEMBER 2014

2 TABLE OF CONTENTS PAYOR BUSINESS MODEL A NEW NORMAL 3 PAYOR DATA NEEDS 4 BIBLIOGRAPHY 8 HCL LIFE SCIENCES & HEALTHCARE 9 LET S CONNECT 9 ABOUT THE AUTHOR 10 ABOUT HCL , HCL TECHNOLOGIES. REPRODUCTION PROHIBITED. THIS DOCUMENT IS PROTECTED UNDER COPYRIGHT BY THE AUTHOR, ALL RIGHTS RESERVED. 2

3 PAYOR BUSINESS MODEL A NEW NORMAL Payors in the US are going through a seismic change because of the internal and the external factors directly impacting their business model. It has placed them in a challenging situation of cost containment and building new capabilities, which will make them more competitive, at the same time. Most of the new capabilities that payors need to develop are broadly influenced by the following four trends: Rise in consumerism An annual census by America s Health Insurance Plans (AHIP) of U.S. health insurance carriers shows that, the number of people with HSA/HDHP coverage rose to nearly 15.5 million in January 2013, up from 13.5 million in January 2012 and 11.4 million in January 2011; an annual growth rate of approximately 15 percent over the last several years. Most enrolment gains in the HSA/HDHP market in 2013 were in the large group market. The share of HSA/HDHP covered lives enrolled in large group plans jumped from 59 percent in January 2012 to 68 percent in January Bottom line cost pressure because of margin reduction regulated by government agencies A report by The Commonwealth Fund states that, the total rebates for 2012 were $513 million, half the amount paid out in 2011, and indicating greater compliance with the MLR rule. Spending on quality improvement remained low, at less than 1 percent of premiums. Insurers continued to reduce their administrative and sales costs, such as brokers fees, without increasing profit margins, for a total reduction in overhead of $1.4 billion. In the first two years under this regulation, total consumer benefits related to the medical loss ratio both rebates and reduced overhead amounted to more than $3 billion. 2 Population health management According to a health industry post on Population Health Management by Ernst & Young, More than 133 million Americans, or about 45% of the population, have at least one chronic condition, which accounts for more than 75% of national health care spending. Identifying these high-risk patients early and implementing proactive disease and case management programs will enable providers and payers to cut down on inappropriate spending and improve patient care. Analysts note that by 2023, improving prevention and disease management could save the US over $1 trillion in direct and indirect costs on seven of the most common chronic diseases. 3 Higher uncertainty caused by regulatory bodies According to PwC s mhealthinsights, Uncertainty in regulatory requirements would likely dampen the growth of mhealth, one of the most powerful emerging tools available to enable greater access to more affordable quality care. According to the PwC-commissioned Economist Intelligence Unit report, Emerging mhealth: Paths for growth, 45% of payers and doctors believe that the application of inappropriate regulations from earlier technologies is hindering the innovation of mhealth , HCL TECHNOLOGIES. REPRODUCTION PROHIBITED. THIS DOCUMENT IS PROTECTED UNDER COPYRIGHT BY THE AUTHOR, ALL RIGHTS RESERVED. 3

4 These trends are leading payors to relook at their Information technology (IT) investments, as it would play a pivotal role in shaping the operational model of the future. In fact, the IT agenda is driven by the following two principles: The change is leading to the creation of new value based payor models, which require analytic driven solutions to solve complex business problems. The global healthcare analytics market is growing at a compound annual growth rate of 23.7 percent from 2012 to That puts just the analytics segment of the healthcare market at $10.8 billion within four years says the industry analysis firm, Markets and Markets. 5 According to IDC s U.S. Healthcare Payer Top Predictions, more than 60% of the surveyed health plans report analytics as a leading investment driver for and 50% of health plans reported consumer analytics investment in % of health plans surveyed listed compliance as a key technology driver and a rising compliance requirement causes 30% of analytics vendors to establish dedicated solutions. 6 Rise in consumerization has made unstructured social data extremely critical for every aspiring customer centric payor organizations. While it is evident that data intelligence is going to drive the businesses of tomorrow, it is not clear whether payors are ready for the change. To gain a better understanding let us first look at what kind of data payors need to focus on for getting business driven insights. PAYOR DATA NEEDS Finance and clinical divisions in payor organizations are most active in getting data driven intelligence. PAYER DATA NEEDS BUSINESS INTERFACE Financial Analytics Clinical Analytics Regulatory Reports (A,B,C,D) Renewals (A,C,D,E,F) Financial Statements (A,D) Patient Health population (A,B,E,F) Clinical Conditions (B,C,E,F) DATA INTERFACE Structured Data Unstructured Data (A) Member Data (B) Claims Data (C) Provider Data (D) Benefit Data (E) Social Feed (F) Other External 1 Copyright 2014 HCL Technologies Limited y The finance division would need analytics for regulatory reporting, employer / individual yearly renewals and various financial statements 2014, HCL TECHNOLOGIES. REPRODUCTION PROHIBITED. THIS DOCUMENT IS PROTECTED UNDER COPYRIGHT BY THE AUTHOR, ALL RIGHTS RESERVED. 4

5 y The clinical division, would need analytics to understand patients demographics and health conditions. It would help clinicians to profile the customer base and develop the right health care model Markets and Markets states that, the current market size of Clinical Data Analytics solutions is $2.25 billion, which is expected to grow at a CAGR of 44.15% to reach $12.26 billion by the end of year To meet the needs of payor organizations, the data comes from four broad sources: member, claims, provider and benefit data, which are housed in various mainframe or bespoke environments and sourced for reporting by creating Operational Data Stores (ODS) and data marts. It is interesting to note that tomorrow, data would also be required from external channels and social platforms, which are completely unstructured. KBM Group reports that, while 61% of health consumers trust information coming from doctors via social media, it drops to 55% for hospitals, 42% for health insurers and 37% for drug companies. 8 The Dilemma Facing Healthcare IT Organizations With data becoming a vital factor, CIO/ CTO organizations have to become more agile and nimble to evolve with the larger organization and its business models. However, there are many other demands: y Enabling faster turn-around time y Processing large amount of data for heuristic analysis y Handling multiple data sets and forms y Building analytics application on the go The traditional model of building master data models and large data warehouses are soon becoming outdated as these work best when you know what to report, for which period, and what data set to look at. As the business is evolving, what is critical today is not relevant tomorrow as data reporting is getting rapidly replaced by user driven analytics. This behavior, is driving the healthcare payor s IT organization to provide the platforms of tomorrow, which can serve data driven insights on demand for the business to take faster decisions. This is easier said than done, as to truly enable the enterprise of tomorrow, it has to completely change the way it gathers, transforms, stores and delivers data insights. Also, it requires huge transformation dollars, which unfortunately CIOs do not have today. 2014, HCL TECHNOLOGIES. REPRODUCTION PROHIBITED. THIS DOCUMENT IS PROTECTED UNDER COPYRIGHT BY THE AUTHOR, ALL RIGHTS RESERVED. 5

6 CIO S ALIGNMENT TO BUSINESS DEMAND From B2B to B2C Customer Centricity Data Driven Decisions Innovation Office HIT Understanding Exists Store Front Analytics Driven Decision Integrated Experience No Clear Strategy Faster Provisioning Fewer Platforms Application Development Interface Sporadic Existence Software Defined Data Center Data Fabric Business Process Platforms 1 Copyright 2014 HCL Technologies Limited Analytics Today It is not that analytics is not done by the healthcare CIO s organization it provides a high yield of business intelligence to the larger organization in areas such as Product Modeling, Customer Engagements, and Provider cost Benchmarking to name a few. The data spreads across areas such as claims, finance, group, care management, network, customer service, provider, member and benefits. The IT organization, source the data in the ODS on a near real-time basis or store it in multiple data banks at scheduled time intervals. Various reporting engines run these data marts to provide business centric reports. As the data sources are getting huge (in petabytes) and unstructured data is coming into play, most of the healthcare organizations are also exploring big data solutions. However, it is not helping them to realize the true potential, because big data or the traditional data warehouses are fundamentally doing the same store large volumes of data in pre-defined metadata structures and get large processing power to run complex/ large queries. Interestingly, even though the processing power has increased, the needle has still not moved from a time to market perspective. The reasons are simple, because payors still need to: y Extract, Transform and Load (ETL) to transform large volumes of data to the desired MDM (Master data) models y Build an application around the new MDM structure to provide data insights Data Lake Combined With API Driven Platform A New Way to Think About Data and Analytics The challenge of getting business aligned analytics is driven by the fact that, at one end, it is overwhelmed by the growth of data and at the other end, by the meteoric increase in business demand for data driven applications. In addition, time to market and advancements in technology is not helping in any form. To add to this list, the 2014, HCL TECHNOLOGIES. REPRODUCTION PROHIBITED. THIS DOCUMENT IS PROTECTED UNDER COPYRIGHT BY THE AUTHOR, ALL RIGHTS RESERVED. 6

7 CIO s organization is saddled with 3-decade old legacy platforms and with no funds for modernization. The only way IT organizations can become relevant, is by tackling both the data and the application problem together not in the traditional context, but by finding the answer to the following questions: y Can we bring all the data (structured and unstructured) into a big data platform without worrying about data structures, ETL scripts, sources and formats? y Can we create a data analytics platform with API (Application Programming Interface) exposed (similar to Facebook or LinkedIn) so that applications can be built rather than as pre-conceived locked in applications? y Can analytics run across the data sets using the APIs to get meaningful outcomes without any restrictions and boundaries? The answers to these question is an absolute yes and it can be achieved through the concept of Data Lake with API driven platform, which can be done in three logical steps: y Big data through Data Lake is a well written concept 9, which primarily forces one to think beyond repositories, data marts, ETL and MDM and imagine a large lake of data with all structured and unstructured data together in it. y 95% of the data will come from old mainframes and existing systems and hence to make the Data Lake concept work, it is critical to unleash data from the legacy environment. HCL has Mainframe to Hadoop connectors, which helps to leverage old legacy data to be sourced in a big data environment and analyze it along with unstructured data. How Analytics is Done Today Data Lake Combined with API Driven Platform SYSTEMS OF RECORDS ENABLEMENT HEALTHCARE IT FUTURE Realize Business Benefits Analytics Enable Existing Systems Platform Driven Organization Build Systems of Engagement Generate Employer/Member Reports Mainframe System Data Leverage Augmented DW Define What is Platform and rationalize environment Based on the definition select few platforms Independent of existing legacy Creative Data Fabrication to leverage existing data Determine Trending Cost Pattern Enable Annual Renewals Market Share Trends Appeals External Systems Data Integration Enable platforms to produce and consume information through an application development interface Focus on business centric application Claims Reporting 1 Copyright 2014 HCL Technologies Limited y The third aspect is building the platforms of tomorrow (Analytics driven platforms) without any dependency on the legacy systems. The application needs to be built with an API mind-set - ability to get any data in any form to any analytical platform for business driven analytics. 2014, HCL TECHNOLOGIES. REPRODUCTION PROHIBITED. THIS DOCUMENT IS PROTECTED UNDER COPYRIGHT BY THE AUTHOR, ALL RIGHTS RESERVED. 7

8 For the healthcare industry to cope with all the macroeconomic changes, insights from data will be paramount. The payors who will exploit it would weather the storm and beat the competition. As everything is data and data-driven analytics, the CIO has the perfect opportunity to lead the transformation that the business desperately needs. The API driven application interface built on a Data Lake concept is the perfect combination every organization should look forward to because it does not need big capital expenditure and can be started as a hobby and as the business sees value, it can be taken to the mainstream. BIBLIOGRAPHY may/1744_mccue_med_loss_ratio_year_2.pdf 3. health_management/$file/health_industry_post.pdf Whitepaper.pdf , HCL TECHNOLOGIES. REPRODUCTION PROHIBITED. THIS DOCUMENT IS PROTECTED UNDER COPYRIGHT BY THE AUTHOR, ALL RIGHTS RESERVED. 8

9 HCL LIFE SCIENCES & HEALTHCARE HCL is a leading provider of Life Sciences and Healthcare Business and Technology services. We are the chosen service provider for enabling new growth drivers for our clients, providing them with industry leading best practices, taking care of their compliance needs and ensuring gold standard process cycle times. Our clientele includes seven of the top ten global pharmaceutical companies, seven of the top ten medical devices companies, six of the top ten health plans, three of the top five CRO s and two of the top three data providers. Equipped with certified technology experts and domain specialists, HCL offers services in critical areas of the life sciences and healthcare eco system such as drug discovery, clinical development, drug safety, regulatory compliance, manufacturing and plant automation, commercial, Healthcare analytics, Population Health Management [PHM], mhealth, member experience management [MEM], fraud, waste and abuse management [FWA]. LET S CONNECT Please feel free to write to us at contact.lsh@hcl.com 2014, HCL TECHNOLOGIES. REPRODUCTION PROHIBITED. THIS DOCUMENT IS PROTECTED UNDER COPYRIGHT BY THE AUTHOR, ALL RIGHTS RESERVED. 9

10 ABOUT THE AUTHOR Shantanu Baruah Life Sciences & Healthcare Technologist He manages executive relationships, defines and creates technology-led business solutions, creates thought leadership, manages account financials, and leads diversified teams. He also leads technology innovation in the LSH space globally. Prior to his current role, Shantanu was responsible for managing one of HCL s top three accounts globally. Also, in the past, Shantanu headed the digital practice for HCL. y 16+ years of experience in Digital, Enterprise Content Management, and Information Access y Active speaker at forums such as IDC, Gartner events, DUMA (EMC User Conference), and EMC Developers conference. He has authored multiple whitepapers in the digital area y Active contributor to the Apple App creation y Involved with several of HCL s large engagements in transition, delivery, and program governance roles y Holds a Bachelor s degree in Science and Masters in Computer Applications; Currently pursuing MBA from NYU Stern y Based in New Jersey, USA 2014, HCL TECHNOLOGIES. REPRODUCTION PROHIBITED. THIS DOCUMENT IS PROTECTED UNDER COPYRIGHT BY THE AUTHOR, ALL RIGHTS RESERVED. 10

11 ABOUT HCL About HCL Technologies HCL Technologies is a leading global IT services company working with clients in the areas that impact and redefine the core of their businesses. Since its emergence on the global landscape, and after its IPO in 1999, HCL has focused on transformational outsourcing, underlined by innovation and value creation, offering an integrated portfolio of services including software-led IT solutions, remote infrastructure management, engineering and R&D services and business services. HCL leverages its extensive global offshore infrastructure and network of offices in 31 countries to provide holistic, multi-service delivery in key industry verticals including Financial Services, Manufacturing, Consumer Services, Public Services and Healthcare & Life sciences. HCL takes pride in its philosophy of Employees First, Customers Second which empowers its 91,691 transformers to create real value for customers. HCL Technologies, along with its subsidiaries, had consolidated revenues of US$ 5.4 billion, for the Financial Year ended as on 30th June 2014 (on LTM basis). For more information, please visit About HCL Enterprise HCL is a $6.5 billion leading global technology and IT enterprise comprising two companies listed in India HCL Technologies and HCL Infosystems. Founded in 1976, HCL is one of India s original IT garage start-ups. A pioneer of modern computing, HCL is a global transformational enterprise today. Its range of offerings includes product engineering, custom & package applications, BPO, IT infrastructure services, IT hardware, systems integration, and distribution of information and communications technology (ICT) products across a wide range of focused industry verticals. The HCL team consists of over 96,000 professionals of diverse nationalities, who operate from 31 countries including over 505 points of presence in India. HCL has partnerships with several leading global 1000 firms, including leading IT and technology firms. For more information, please visit Hello there! I am an Ideapreneur. I believe that sustainable business outcomes are driven by relationships nurtured through values like trust, transparency and flexibility. I respect the contract, but believe in going beyond through collaboration, applied innovation and new generation partnership models that put your interest above everything else. Right now 95,000 Ideapreneurs are in a Relationship Beyond the Contract with 500 customers in 31 countries. How can I help you?