The Road to Transformation
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The document discusses transforming a healthcare payer's processes and rules to meet its business vision. It describes how Blue Slate Solutions helps clients (1) improve operations through process optimization and technology modernization, (2) has experience across healthcare payer functions, and (3) can help ensure an organization's current architecture and rules are flexible to meet future needs.
The Road to Transformation
- 1. The Road to Transformation Ensuring your data processes and rules will meet the business vision data, for today and tomorrow September 8, 2011 © Blue Slate Solutions 2011
- 2. About Blue Slate Solutions • Improve operations - optimize processes, I ti ti i connect disparate systems, introduce relevant Rules technologies, manage data • Clients include 2 of the top 3 and 4 of the top 20 health payers including 9 BCBS plans h lth i l di l Solutions • More than 100 healthcare-specific projects Process Data spanning more than 20 different healthcare entities, mostly Blues or their subsidiaries • Experience across the full spectrum of Project & Change healthcare payer functions and departments Management Shawn Firehock David Scholl • 15 years BPM experience • 20 years general within healthcare payers, management and business insurance and financial leadership at GE services • Certified Master Black Belt in • Designed pre- Six Sigma (process quality) adjudication platform for a Blue • PM/BA on 9 workflow automation programs within • Worked with several healthcare payers Blues on transformational change 2 © Blue Slate Solutions 2011
- 3. Strategic Focus on Business Process Management Process BPM Data Rules Architecture Smart Approach. Extraordinary Results. 3 © Blue Slate Solutions 2011
- 4. Blue Slate BPM Solutions Project Portfolio BluePrint Prioritization Process Drive Change Analysis ROI Management System Tool Selection Integration Smart Approach. Extraordinary Results. 4 © Blue Slate Solutions 2011
- 5. Blue Slate in Healthcare Payers Clients 4 of the top 20 US Healthcare Payers 2 of the top 3 national payers 9 Blue Cross Blue Shield plans 3 Medicare Administrative Contractors 1 Top 5 Third Party Administrator Experience 100+ healthcare-specific projects 25+ different healthcare entities 5 © Blue Slate Solutions 2011
- 6. Our client 40 year old US payer, 2500+ employees across multiple locations serving several million subscribers Will current architecture serve future business vision? How can we surpass our competition? 6 © Blue Slate Solutions 2011
- 7. Two tracks; one destination Current State Applications Grounding G di Technologies T h l i Strategy Organization Business Technology 7 © Blue Slate Solutions 2011
- 8. Business Track © Blue Slate Solutions 2011
- 9. Business methodology Discover and validate strategy Ground leadership in possibility Conduct cross-functional interviews 9 © Blue Slate Solutions 2011
- 10. Maturity and relative IT spending 10 © Blue Slate Solutions 2011
- 11. Organizational maturity model: transformational change Level 1 Level 2 Level 3 Level 4 Level 5 Informal/Ad hoc Formal/Documented Integrated Strategic Optimized Individual Success Enterprise Collaboration People “Fire fighting is a way of Highly Agile life.” Strategically focused Uncoordinated Rewarded on Enterprise relationships Success In competition Process and Ad Hoc Adaptive Chaotic Opportunistic Technology Inconsistent Proactive Agile Communication Ad Hoc Preventive Chaotic Highly Adaptive No single source of truth g Opportunistic pp Community based (All stakeholders) Measurement Ad Hoc Data is used to evaluate Manual and select process People based People-based improvements Budget Ad Hoc Opportunistic Uncoordinated Strategically Focused Hidden spend Individual Project based I di id l P j t b d 11 © Blue Slate Solutions 2011
- 12. Resulting transformational maturity progression Level 1 Level 2 Level 3 Level 4 Level 5 Informal/Ad hoc Formal/Documented Integrated Strategic Optimized Individual Success Roles well understood Program level Collaborative Enterprise Collaboration “Fire fighting is a way of Coordinated Relationships Coordination Aligned Highly Agile life.” 2a Commonality driven2b Performance Measured Data driven Strategically focused People Uncoordinated Customer focused g Standardized training Thinkers vs Doers Rewarded on relationships Rules assume low level Enterprise Success In competition tasks Ad Hoc Emerging Defined Aligned Adaptive 1 Chaotic Standardized Structured Disciplined Opportunistic Process and Inconsistent Isolated Measured Predictable Proactive Technology Repeatable 7 Competent 6 Quantitatively Agile Measured Ad Hoc Common language Common language Aligned across Preventive Chaotic emerging 2a Standards Training and outside Highly Adaptive No single source of truth Gaps understood and Tied to Performance Enterprise Opportunistic Communication reconciled Systemic Quality Checks Community based (All Quality checks 8 Shift burden to Supplier t k h ld ) stakeholders) Ad Hoc Standardized 2a Proactive Qualitative Data is used to evaluate Manual Repeatable Aligned assessment and select opportunities Measurement and People-based Emerging proactively Automated Control 5 Silo Emerging Automation Enterprise Portfolio Ad Hoc Emerging Spend Visibility Clear Spend Visibility Aligned Opportunistic Uncoordinated Coordinated 2 Program Approach Predictable Strategically Focused Hidden spend Emerging Control Controlled Agile Budget Individual Project based Coordinated Projects ROI visibility 12 © Blue Slate Solutions 2011
- 13. Actionable 13 © Blue Slate Solutions 2011
- 14. Deliverables • Definition of future state Architectural paradigm System logical diagram System physical diagrams • Detailed roadmap to target architecture, organization and/or process • Set of Quick-Win and Transformation project plans (ROI, Staffing, Timeline) 14 © Blue Slate Solutions 2011
- 15. Technology Track © Blue Slate Solutions 2011
- 16. Technology methodology Discover IT organization’s alignment and skills Examine technology capacity and flexibility Assess application functionality and data 16 © Blue Slate Solutions 2011
- 17. Architectural maturity model: transformational change Standardized Business Business Silos Optimized Core Technology Modularity Companywide Plug and play Plug-and-play Local IT Shared technical IT Capability standardized business process applications platforms process or data modules ROI of local Cost and quality Business Speed to market, business Reduced IT costs of business Objectives strategic agility initiatives operations 17 © Blue Slate Solutions 2011
- 18. The business operates, but how? Classic Optimized Mostly human with some static Automated, flexible, DSL with Rules systems human for exceptions Manual, escalation by Automated, SLAs, consistent, cross- Workflow complaint, process knowledge department by b experience within d i i hi department Electronic repository, single location Paper-based, curriers, access Documentation challenges ( g (timeliness, copies) ) for all documents, effective retention and security Ad-hoc, broadcast, many pull Communication requests Just-in-time, targeted Stove-pipe (department, purpose and technology), Shared services, integrated data, Systems redundant functionality, y systems of record y duplicated or inaccessible data 18 © Blue Slate Solutions 2011
- 19. Systems and stovepipes 19 © Blue Slate Solutions 2011
- 20. Target architecture View Presentation Tier Layout Online Provider WS Services iPhone Android Facebook Security Application Tier Request ID Notifiier NRQT … Aggregation Tracking MAD Business Rules SDO Services / Business Tier Work Flow canonical data models Transactions Security y Security Logging Member Data Provider Data Claim Data Other Service Service Service Service Service Services… Integration Tier object domain j Data abstraction DAO O-R O-XML O-Unstructured O-API / WS O-Screen Scrape Transactions Security native/proprietary domain Enterprise System Components EIS Tier Persistence Host Systems Document Mgmt Transactions System Categorization OLTP data sources Indexing Workflow Engine Messaging Security LDAP OLAP data repositories sources Rules Engine ETL 20 © Blue Slate Solutions 2011
- 21. Deliverables • Definition of future state Architectural paradigm System logical diagram System physical diagrams • Detailed roadmap to target architecture, organization and/or process • Set of Quick-Win and Transformation project plans (ROI, Staffing, Timeline) 21 © Blue Slate Solutions 2011
- 22. Keys to Leading Transformational Change Align Architect Measure Iterate Apply 80/20 Avoid the Big Bang Measure/Validate 22 © Blue Slate Solutions 2011
- 23. Kick-start techniques Leadership Qualifiers and competes High-value High value data Key process standardization y Commodity technology Meaningful POC opportunities 23 © Blue Slate Solutions 2011
- 24. Questions? 24 © Blue Slate Solutions 2011
- 25. Case Study © Blue Slate Solutions 2011
- 26. Medicare Administrative Contracting 26 © Blue Slate Solutions 2011
- 27. Problem At A Glance Our Client, a Medicare Administrative Contractor (MAC) looking to maintain Problem their existing contract and grow. • Client estimated they needed >30% reduction in cost/claim while taking on 2X workload Solutions • Cost Driven Program Strategy • Prioritized program elements • Detailed requirements • Impactful solutions • Client self-sufficiency 27 © Blue Slate Solutions 2011
- 28. The ‘As-Is’ Process Inbound / Mailroom Appeals Medical Review Overpayments Outbound Correspondence Process QA 28 © Blue Slate Solutions 2011
- 29. Define the Strategy At A Glance Our Client, a Medicare Administrative Contractor (MAC) looking to maintain their existing contract and 1 Define the Strategy grow. Solutions • Become paperless • Cost Driven Program • Optimize Key Business Processes Strategy • Leverage legacy systems and technologies • Prioritized program elements • Joint ownership between IT and Business • Detailed requirements • Change management workshops sponsored and • Impactful solutions attended by Senior Leadership – ensured buy-in • Client self-sufficiency from the onset 29 © Blue Slate Solutions 2011
- 30. Prioritize the Program Elements At A Glance Our Client, a Medicare Administrative Contractor (MAC) looking to maintain their existing contract and grow. Solutions • Cost Driven Program 2 Prioritize the Program Elements Strategy • Prioritized program • Used a Six Sigma approach (QFD) in planning elements • Focus on Centralized processes and paper- • Detailed requirements heavy processes • Impactful solutions • Client self-sufficiency • Implemented Governance at all levels including monthly Executive Steering committee meetings 30 © Blue Slate Solutions 2011
- 31. Gather Detailed Requirements At A Glance Our Client, a Medicare Administrative Contractor (MAC) looking to maintain their existing contract and grow. Solutions • Cost Driven Program Strategy • Prioritized program elements 3 Gather Detailed Requirements • Detailed requirements • Impactful solutions • Involved Technical team from the start • Client self-sufficiency • Used ROI and Productivity metrics to drive the To-Be solutions • Detailed Use Cases / Business Rules 31 © Blue Slate Solutions 2011
- 32. Built Impactful Solutions At A Glance Our Client, a Medicare Administrative Contractor (MAC) looking to maintain their existing contract and grow. Solutions • Cost Driven Program Strategy • Prioritized program elements • Detailed requirements 4 Built Impactful Solutions p • Impactful solutions • Client self-sufficiency • BPM/workflow to streamline high impact processes • Leveraged legacy DBs and data warehouse. • ECM implemented to directly launch new workflow p y • IVR feeds workflow - improved caller experience • Data masking tool to allow developers/testers to work with non-production data (security) • Manager portal provide real time view of inventory 32 © Blue Slate Solutions 2011
- 33. Contact Center Optimization 33 © Blue Slate Solutions 2011
- 34. Enable Client self-sufficiency At A Glance Our Client, a Medicare Administrative Contractor 5 Enable Client self-sufficiency (MAC) looking to maintain their existing contract and • Continual mentoring and technical guidance to grow. Client IT team Solutions • Developed systematic Knowledge Transfer • Cost Driven Program sessions Strategy • Client is now self sufficient • Prioritized program elements • Detailed requirements • Impactful solutions • Client self-sufficiency 34 © Blue Slate Solutions 2011
- 35. The Payoff At A Glance Our Client, a Medicare Administrative Contractor (MAC) looking to maintain their existing contract and grow. Solutions • Cost Driven Program Strategy Client Successfully Awarded the Contract ! • Prioritized program elements • Measured cost reductions of 25% to 40% in • Detailed requirements automated departments with seamless transition to p • Impactful solutions new level of workload (2X) • Client self-sufficiency • Improved Caller (customer) experience • Change Management mindset starting to take hold throughout organization - Workforce less intimidated by continuous market dynamics / changing requirements 35 © Blue Slate Solutions 2011
- 36. Measurable Results • Reduction of Cost per Claim and PMPM Cost • Increased throughput with minimal impact on operational cost • Leveraging existing technology investments through multi-tiered architectures and web services • New technologies increase competitive position by getting closer to providers and members • More secure systems and data improve compliance and minimize corrective actions and fines 36 © Blue Slate Solutions 2011
- 37. Winning strategies to transform challenges to results • Engage leadership and cross-functional teams and establish strong project governance models • Identify and prioritize opportunities, and formalize as projects • Question the status quo – search out redundancies and hidden factories • Leveraging existing technology • Use rules and workflow to automate • Introduce relevant and appropriate new software for maximum impact p 37 © Blue Slate Solutions 2011
- 38. What’s on your mind? 38 © Blue Slate Solutions 2011