Abstract

A large healthcare organization has launched a comprehensive strategy to objectively assess and improve both clinical strategy and operations so that administrative costs could be optimized and care costs reduced. This strategy required rapid termination of an existing care management vendor relationship and a subsequent build of services and capabilities in house. Using the leading Total Health Management (THM) framework, SDLC Partners quickly deployed a team to initiate this strategy by analyzing and reengineering over 500 processes and implementing four major clinical platforms in just eight months! The health organization was able to save over $15 million annually in administrative cost savings, increase utilization of preventative wellness programs as well as improve healthcare product and service market penetration.

The Challenge

A large healthcare organization has launched a comprehensive strategy to objectively assess and improve both clinical strategy and operations so that administrative costs could be optimized and care costs reduced. The goals were to build a flexible model that allowed collaboration with and support for new provider delivery models, be more responsive to both individual and group customer needs, and become more cost effective while continuing to provide value and quality care to members. As part of this strategy, the health plan needed to replace an existing multi-million dollar clinical outsourcing relationship, construct a new medical management operating model and implement corresponding clinical platforms in just eight months! This required a cost-effective partner with clinical operations expertise and thought leadership with transformation and technical execution services.

The Solution

Using the industry leading Total Health Management (THM) framework, SDLC brought on a team of approximately 40 clinical and re-engineering specialists, program/project managers, technical architects, and web/report developers to deliver the following:

Transformation

Analyzed and re-engineered over 500 processes (e.g., case, disease, wellness, utilization, provider call center, medical policy, pharmacy, etc.).

Requirements & Design

Led the development of use cases and requirements for major clinical applications and associated health plan interfaces (e.g., MEDecision Alineo, WebMD, Healthwise Connect, and Verisk Health Sightlines Intelligence).

Reporting

Developed reports in Business Objects and SAS to deliver intelligence across the clinical platforms and the plan’s enterprise data warehouse environment.

Build & Test

Worked with the aforementioned vendors and configured the applications to suit the health plan’s needs. SDLC Partners was also responsible for executing unit, integration, performance, and user acceptance testing.

Custom Build

Constructed a tasking / throttling application to further refine identified member pools with risk scores to a subset of targeted members to be used by health coaches for appropriate interventions. In addition, SDLC Partners developed the portal functionality to integrate WebMD into the health plan’s member web site.

Change Management & Training

Supported the health plan by producing desktop reference guides, business process manuals and procedures, conducting end-user training, and coordinating and managing go-live support along with infrastructure logistics for over 300 personnel.

Proof of Concept

Worked with the health plan’s procurement department to conduct testing proof of concept scenarios and associated scoring with qualified vendors. Identified the need to add two additional vendors and one custom application based on new process designs and vendor capabilities.

Total Health Management

Built around the healthcare management continuum of Identify, Enroll, Retain, SDLC Partners has developed a comprehensive care delivery experience and proven framework called Total Health Management (THM) to deliver customized, executable consumer-driven accountable care models which enable healthcare organizations to provide sustainable and effective healthcare management. The THM Framework builds integral capabilities into each phase of the continuum, resulting in an overall optimal program that identifies and captivates the right members at the right time and retains their loyalty through the right programs and incentives. In addition to creating a consumer-focused program, the THM concurrently enhances a collaborative relationship with payers and providers to ultimately improve the quality of patient care while reducing costs for everyone. The THM framework is a complete solution that makes use of SDLC Partners’ unique ability to bridge business and IT.

The Results

  • Reduced administrative cost by over $15 million annually
  • Increased utilization of preventative wellness programs by proactively identifying gaps-in-care
  • Improved asset efficiencies and employee productivity reducing clinical variation through streamlined care delivery models
  • Increased healthcare product and service market penetration by designing care management programs to attract and retain profitable customers
  • Integrated four new clinical platforms to support plan and provider growth strategies
  • Developed first of its kind “360” degree view of member and “Single Nurse Model”
  • Produced over 50 health promotion and conditions, addressing risk reduction and productivity
  • Created a new, more robust Personal Health Record (PHR) and member portal experience
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