media, etc., is now the starting point for consumer- facing platforms. • Risk-pooling: Multi-carrier exchange provides oppor- tunity for better risk pooling through the use of tech- nologies, such as EMR and HIE records, that provide a more accurate health history.
Challenges and strategic considerations for private exchanges
Health plans need to address several challenges while setting up private exchanges to increase member base: • Operational model: In a multi-carrier environment, the governance model, execution strategy and business rules definition are significant challenges. Although health plans can opt to set up a single-carrier exchange, the complete execution strategy definition is still a challenge.
• Brokers: Exchanges cannot simply be the new portal for broker interaction. Just as life insurance, property and casualty (P&C) insurance, and travel and leisure sectors redefined the role and opportunities of the agent/broker, private exchanges (and the health insur- ance industry) need to do the same. Services provided by brokers will transform from primarily sourcing and registration to value-adds that will support improved health delivery and cost take-out.
• Infrastructure set up and integration: Serving millions
of consumers requires a well-defined infrastructure strategy based on population characteristics and insur- ance market environment. Integration with health plan administrative and operational systems is crucial for data integrity as well as an automated and accelerated transactional environment. Sound integration strategies reduce administrative burden and associated costs.
• Consumer acquisition and relationship management: Assessing the market potential and developing new strategies are required for consumer acquisition and retention.
• Marketing strategy: Differentiation for the health plan has to be achieved through marketing, outreach and communication plans.
• Adverse selection: Innovative approaches are needed to address the issue of adverse selection and must be sup- ported with appropriate risk adjustment mechanisms and strategies.
• Data security and privacy: While implementing pro- cess automation and integration, the data flow needs to be controlled with a secure channel and requires stakeholder buy-in as well as infrastructure availability.
Setting up private exchanges: Strategic and operational approach People: Governance for a private exchange is typically by an independent body comprising of the IT platform provider,
Health plans need to cover both IT and opera onal services in a harmonized manner Challenge
Strategic considera ons Exchange opera onal model
• Innova ve consumer engagement and revenue models • Well-defi ned stakeholder management plan and governance set up with business process management for plan and benefi ts selling • Upfront Value Realiza on Framework set up
Consumer acquisi on and rela onship management
Marke ng strategy defi ni on and broker support
Adverse selec on Infrastructure and integra on
• Rich user experience, mul -point decision support • Support for aff ordability • 24/7 consumer support • Social media support, educa on and outreach
• Plan marke ng • Educa on and outreach: webinars, seminars, online educa on • Mobility support for educa on, surveys • Case management, quo ng and educa onal services for brokers
• Decision-support tools, mechanisms • Risk assessment, adjustment, pooling strategy
• People, process and technology integra on for end-to-end service landscape, with process automa on • Seamless interac on and exchange of informa on and transac ons between health plan systems, consolidated billing
• Scalable and secure cloud-based infrastructure, hosted deployment model, privacy support
HEALTH MANAGEMENT TECHNOLOGY November 2012 13
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