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Leveraging Expertise in the Payer Market

Michael Byers, CEO, HighRoads
Michael Byers, CEO, HighRoads

Michael Byers, CEO, HighRoads

What significant changes did the Big Data segment witness in 2013? What did these changes mean to vendors and customers?

The single biggest influence in our sector was the Affordable Care Act (ACA) and the implementation changes that affected both of our markets – payers and employers. With the advent of public and private exchanges, it put a spotlight on how well payers and employers were managing the complexities of health benefits data for millions of employees. Accurate recordkeeping and effective plan management is essential to moving employees from self-funded plans to private exchanges, as an example.

Enterprise data management is also critically important to  handle plan communication compliance mandatesas a result of the ACA.The advent of public and private exchanges presented payers with the opportunity and challenges of a newly fragmented marketplace in which consumers could potentially choose from more plans. It was a classic data challenge since payers need to manage the data for a myriad of plans and a diverse consumer base, and they must do so in an environment in which the consumer expects real-time response.

Healthcare IT vendors participating in this space must have solutions that are both agile and scalable since the market landscape continues to evolve. Data management solutions must be able to address the new, more fractured healthcare market and provide organizations with a means of fulfilling consumer needs, mitigating risk and meeting compliance demands. 

What are some of the changes you had anticipated would happen in 2013 but did not happen?

We had hoped it would become more evident that data management was absolutely essential to the success of the new health care landscape. The problems with the rollout of public exchanges – the website issues and fixes – highlighted the need to have a good data foundation in place with consistent workflows to implement the changes required by this significantly different healthcare marketplace

Can you paint us the picture of how the landscape for this industry segment will change in 2014? What are some of the broader trends you are closely watching?

The trend we particularly see is payers looking to consolidate a number of data sources into one perspective. One of the ACA market drivers is the Medical Loss Ratio (MLR), which sets a percentage of payer spend on administrative, or non-claims expenses. This further opens the door to cloud-based solutions such as HighRoads, as payers are looking for a way to cut IT spending and implement a more managed environment. 

With a better data-managed environment, payers can use data analytics to have greater insight to their customer base. In an exchange environment, payers will need centralized, consistent and easy-to-access data to better match the needs of their customers. 

With the ACA, one new target market is the “young invincibles,” healthy young adults whom payers will need to attract to deepen their risk pool and cut costs. Payers will need a well-managed plan data repository in order to determine the enticements that will convince this target market to enroll. They will then have the capability to test different combinations of services against sales data, to see which offering resonates with the young consumer.

How would customer spend change in 2014 for the Big Data segment? What makes you think customers will be buying more/less?

Published research estimates healthcare IT spending by payers and providers to increase to more than $34.5 billion in 2014. The ACA’s regulatory guidelines and the need to respond to the changing consumer marketplace will drive spending. Big data solutions will be a part of this as payers move from legacy systems developed in a different market era to innovative systems and software that addresses data management, analytics and productivity.

What's in store for your company in 2014?

In 2014, we will continue to expand our presence and leverage our expertise in the payer market with our cloud-based, SaaS solution for benefits plan management and health care compliance. Our goal is to keep payers competitive, compliant and market-ready in the post-ACA world by centralizing, managing and repurposing product plan data. Payers will benefit from our patented technology that configures their data so that changes are made once and propagated throughout systems, processes and documents. We have deep experience in this space over the last 15 years, providing large, complex clients significant cost savings by replacing manual tasks with an automated system. We will also continue to serve our Fortune 500 employers as they respond to changes as a result of the ACA, including the transition of employees to a private exchange should they make this decision.

We are also marketing our Medicare Advantage (MA) governance solution to payers looking to enter into or expand their MA footprint. Using our comprehensive system of record for all benefits plan data, payers can eliminate manual, error-prone processes that inevitably incur costly penalties and lost time in competing for, and retaining, MA customers.Because MA plans are regulated by the Centers for Medicare & Medicaid (CMS), penalties for errors can be severe, including preventing the payer from expanding into new markets. Medicare is a big data challenge.  According to CMS, by 2015, the volume of Medicare claims data will grow from 370 terabytes to 700 terabytes. For Medicaid, 30 terabytes of data will multiply to 100 terabytes. Without a benefits plan management system to provide a source of truth, big data could be a big problem for payers looking to pursue this market opportunity.

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