Smarter Healthcare: Improving Payer-Provider Collaboration

Transcription

1 Smarter Heathcare: Improving Payer-Provider Coaboration TriZetto and IBM deiver performance and reiabiity to reduce operating expenses and improve care efficiency

2 Payer Chaenges and Supportive IT Soutions Escaating Provider Costs and Risks Need Rea-time Payer-Provider Coaboration dvanced Eigibiity Soution at Providers Location Provider POS Direct Soution at Payer s Location High Performance and Reiabiity Soution rchitecture Enhancing Payer-Provider Coaboration Infrastructure Matters: IBM Workoad Optimized Systems Smarter Heathcare Software from IBM Improves giity and Operationa Efficiency For more information Heathcare payers and providers today face enormous chaenges in transitioning to the accountabe care mode where provider reimbursements are tied to the quaity and cost of care. The quaity aspect has three factors: safety; vaue; and appropriateness. Centra to addressing these factors is the issue of data integrity and connectivity. Payers and providers need the right information at the right time to ensure correct decisionmaking to optimize care. From a technoogy standpoint, IT coaboration between payers and providers is fundamenta to this goa. Payers must continue to gain administrative efficiencies, impement innovative payment modes to better aign incentives towards heath outcomes and disease prevention, and buid new aiances with consumers and poicymakers to reduce costs. Likewise, providers must improve the efficiency of current deivery modes and must move away from a reactive mode of care deivery to a proactive mode. This requires robust information technoogy (IT) soutions to provide faster, more efficient heathcare deivery with fewer errors, especiay in the context of today s changing reguations. n industry eader with decades of experience in deivering innovative heathcare IT soutions,trizetto heps improve administrative efficiency and quaity of care at ower cost by enabing a more coaborative heathcare community, committed to transforming the way heath is managed and care is deivered. These offerings incude comprehensive enterprise soutions for core administration, care management, portas, payer-provider coaboration, revenue cyce management and others. To enabe the necessary quaity of service, these soutions require a robust, enterprise IT infrastructure. For over 25 years, IBM and TriZetto have had a deep partnership and technica coaboration, with IBM suppying the infrastructure required to run TriZetto software. IBM provides an optimized enterprise-cass IT infrastructure consisting of servers, storage, networking and software to deiver data integrity and connectivity soutions. Components incude: TM Servers: IBM Power Systems, x86 servers Storage systems: IBM DS8000, IBM XIV Storage System, TM IBM Storwize famiy, IBM FashSystem famiy Pre-configured, pre-integrated infrastructure: IBM PureFex System Networking Software: IBM WebSphere, IBM Stering Connect:Direct This comprehensive integrated architecture offers payers and providers a very secure, reiabe, high performing and scaabe IT environment that enhances coaboration to improve operationa efficiency. Together IBM and TriZetto support sma to very arge-scae depoyments with mutipe appications integrated to provide a robust soution for payers and providers of a sizes. Reguar performance testing and benchmarking provides proof points for TriZetto cients of a we-supported, optimized, resiient, and secure soution. Chaenges for Payers Payers Must Coaborate Heathcare Soutions 2

3 Chaenges for Payers Payers and providers today face enormous chaenges in transitioning to the new modes of care where provider reimbursements are tied to the quaity, cost of care, and patient experience. The foowing figure depicts key participants in today s emerging heathcare ecosystem incuding payers and providers who must be connected and must exchange trusted data. This requires robust information technoogy (IT) soutions to provide faster, more efficient heathcare deivery with fewer errors. One of the greatest barriers to progress is coordination. Payers and providers need the right information at the right time to aow optima decision making, but too often it is ocked up in a sioed system. Today, data integrity is compromised in two ways. First, data is scattered and isoated in severa different sios. This is true for both big data reating to information about diseases and their treatment and sma data generated by an increasing proiferation of sensors and devices attached to patients to monitor their condition. The data is often separated by technoogy, administrative, and poitica barriers that make it very difficut for providers to design timey and optima care and for payers to vaidate reimbursement caims. Second, semantic differences cause confusion. Even common medica conditions such as hypertension or diabetes are described in severa different ways in patient records by different hospitas and doctors. nd these in turn may be described differenty in caims records. Coding errors aso creep in during the data entry process. of this can resut in significant differences between caims data and cinica data for the same medica condition. nd when patients undergo treatments at mutipe hospitas during a course of treatment, a of the above is exacerbated. Figure 1: The Heathcare Ecosystem Chaenges for Payers Payers Must Coaborate Heathcare Soutions 3

4 Payers Must Coaborate New modes of care require a comprehensive effort on the part of both payers and providers invoving modifications to cuture, processes, and technoogy. From a technoogy standpoint, a unified IT coaboration between payers and providers can be fundamenta to this endeavor. Payer Chaenges and Supportive IT Soutions Payers primary chaenges incude member retention through customer satisfaction. Further, providers expect effective payer practices that reduce processing time of transactions. To overcome these chaenges, payer organizations are focusing on care management that reduces administrative costs in addition to improving the efficiency of their operations. For better resuts, payers and providers of a sizes shoud invest in modern heathcare IT that enabes them to automate operationa tasks associated with core heathcare management. Escaating Provider Costs and Risks Today, as patients face rising costs for heathcare services, providers are being forced to take on payment responsibiities and risks. Compex manua, abor intensive, error-prone and dupicate administration and payment transaction processes proong providers revenue cyce. Providers shoud reduce time and money spent on coecting patient payments and the administrative tasks. Need Rea-time Payer-Provider Coaboration There is an urgent need to create a trusted reationship between the payer and provider communities to improve operationa efficiencies for payment and other critica administrative processes and to compy with new heathcare programs. Reatime payer-provider coaboration wi hep transform core heathcare provider business processes, enabing them to reduce costs and risks. For exampe, with increased transparency on eigibiity detai for decision making at the point of care and rea-time access to caims information, providers can prequaify patients for care procedures in rea-time whie reducing payment risks and time and money spent in coections.the foowing figure iustrates many different heathcare organizations interact with the individua and therefore need to coaborate to deiver higher care quaity at reduced costs. Manage Trading Partners Figure 3: Vaue of Payer Provider Coaboration Enabe new payment modes (fee-for-service > fee-for-vaue) Hep providers deivers more efficient / effective care Figure 2: Payers can coaborate to deiver higher care quaity at reduced costs Chaenges for Payers Payers Must Coaborate Heathcare Soutions 4

5 With over 25 years of partnership and technica coaboration, TriZetto and IBM are transforming the way heath is managed and care is deivered. Key attributes incude a portfoio of soutions that address the ever increasing heathcare industry chaenges such as rising costs, reguatory changes and increased customer expectations. Payers and providers of a sizes benefit from this ong-term coaboration, deep heathcare industry experience and a range of soutions and technoogy enabing payers and providers to: Integrating rea-time administrative and cinica toos PP L C I T IO N TIE R D T B S E T IER Reimbursement Reduce administrative costs and business risk Support cients compiance requirements with new reguations in the Patient Protection and ffordabe Care ct (PPC) Improve communication and coaboration chieve higher patient/member satisfaction Improve patient outcomes at reduced costs of care R IE T R E V WEB SER IBM Trizetto ppication rchitecture S TO R G E IBM and TriZetto address these requirements through their: Empoyee Productivity ccuracy and Efficiency Innovative capabiities Reiabe, and consistenty high-performing soutions Outstanding support backed with reguar and rigorous performance benchmarking and testing. Reduce Cost Figure 4: IBM-TriZetto Partnership Chaenges for Payers Payers Must Coaborate Heathcare Soutions 5

6 Heathcare Soutions n industry eader with decades of experience in deivering innovative heathcare IT soutions, TriZetto improves administrative efficiency and quaity of care at ower cost by enabing a more coaborative heathcare community, committed to transforming the way heath is managed and care is deivered. TriZetto partners with more than 350 heath pan and benefit administration cients serving more than 180 miion heathcare consumers and more than 230,000 care providers.trizetto s comprehensive portfoio of software soutions benefits both payers and providers. Reduce the cost of coecting payment. Reducing the caims processing cyce from days or weeks to potentiay a matter of seconds heps to cut costs, increase efficiency and shorten the revenue coection cyce. This heps to ower the cost of care and enabe providers to improve care quaity. TriZetto s Revenue Cyce Management (RCM) soutions hep physicians, hospitas and heath systems simpify business processes and get more accurate payments quicky. More than 230,000 care providers trust TriZetto medica caims processing soutions to simpify caims reimbursement and revenue management. Over 400 Practice Management (PM) /Eectronic Heath Record (EHR) soution providers are aso under contract with TriZetto. Key benefits for providers incude: Payment coection at the point of service (POS).Providers can more accuratey cacuate patient financia iabiity and adjudicate caims at the point of service, enabing them to coect payment when services are rendered, rather than days or weeks ater. Streamined interaction with payers. Connect the providers who deiver care in rea-time to the heath pans that pay for it, to reduce waste, paperwork and phone traffic that sow the fow of revenue and increase the cost of heathcare. Figure 5: Integrated Functionaity and Vaue cross Enterprise Business Cyces for Payers dvanced Eigibiity Soution at Providers Location TriZetto offers a broad set of soutions that payers and providers can use to hep improve coaboration and exchange data in rea-time. This incudes the dvanced Eigibiity Soution a ightweight porta connected to a rich portfoio of back-end enterprise cass appications impemented at payers ocations. This soution makes it easy for providers to better cacuate accurate patient payment responsibiity at the point of service and can hep reduce bad patient debt and the time and money providers spend coecting patient payments. With just a few cicks, the dvanced Eigibiity Soution aows providers to: Instanty cacuate a patient s payment responsibiity, incuding co-pays, deductibe baance and co-insurance, based on services entered at the time of query. Identify potentia payment deays, such as the need for prior authorization and services not covered by a patient s insurance. Run a query typicay within seconds at any point during the patient encounter before they arrive, at check-in and/or before they eave the office. Chaenges for Payers Payers Must Coaborate Heathcare Soutions 6

7 Unike other rea-time eigibiity toos, TriZetto s soution directy connects providers through payers Point of Service (POS) to back-end caims processing systems, providing a eve of eigibiity detai found previousy ony with caim submission. Now, provider scan receive detaied and accurate patient iabiity information based on provider-specific contracting, payer network rues, coinsurance, co-pays, deductibes, patient not covered items and services covered by Heath Reimbursement rrangement (HR) funds. piot test of the dvanced Eigibiity Soution with 60 providers in the BueCross BueShied of Tennessee network found the soution running on IBM Power Servers and IBM Storage Systems, provides the infrastructure needed to anayze a the required data and support the soution. This enabed better customer service, owers heath care expenses and provides better medica management. Provider POS Direct Soution at Payer s Location This TriZetto soution, cacuates patient financia iabiity at the point of service. Providers can coect payment at the time services are rendered or, in some cases, even before the patient s visit rather than days or weeks ater. That means providers get faster payments and payers get fewer surprise costs. The provider POS Direct soution gives providers onine access (through portas ike the dvanced Eigibiity Soution) to the payer's core administration system in order to update, submit or view reevant data. The provider's staff can use the appication to submit transactions in rea time when scheduing appointments or when the patient is checking in or out. This can be accompished via a standard web browser or Eectronic Data Interchange (EDI). With Provider POS Direct, payers can: Providers Gateway EDI + Customer & Partners Other(OpenPI) TriZetto Trading Partner Soution Patform vaiabe HIP Transactions Rea-Time Transcations Rea-Time Exchange(10 secs) 2013 Rea-TimePayment ssurance Rea-TimeCaims Editing 2013/14 Cinica Insights Care uthorizations Payers Market TriZetto Enterprise Core dministration,utiization, Care and Disease Management (UM,CM,DM) Non-TriZetto Patform (Open PI) dditionay this test found that the advanced eigibiity soution: Reduced cas to payers more than 55% reduction for some 1 practices Eased patient iabiity coections. With the dvanced Eigibiity Soution, we can et patients know what services are not covered and how much they are going to owe, even before their appointment. This heps increase patient revenue from the get-go and improves patient reations by heping them make informed decisions about the services they receive, said an office manager and administrator at a Tennessee pediatrics practice. Increase administrative efficiency by reducing ca voumes from members and providers, and by reducing pending/rejected caims that require manua intervention. Improve member and provider satisfaction and reduce the cost of churn. Reduce the cost of care by incentivizing providers to offer better discounts when negotiating contracts. The foowing figure shows integrated functionaity where providers get advanced payment adjudication and payers get fewer surprise costs. MEMBER CCESS EMPLOYEE CCESS PROVIDER CCESS Microsoft Windows IBM x86 Websphere Sybase Orace Microsoft IBM DS8870 IBM x86 IBM Power 750 pache IBM Storwize v7000 CUSTOM DEVELOPED SOLUTIONS 3rd PRTY SOLUTIONS ELECTRONIC DT EXCHNGE (EDI) Figure 6: Payer Provider Coaboration Mode Workfow Chaenges for Payers Payers Must Coaborate Heathcare Soutions 7

8 IBM and TriZetto continue to have a strong, ong-standing partnership that provides technica coaboration to drive continuous improvement and customer vaue. IBM provides a robust, reiabe, high-performing patform to host TriZetto appications. Today, approximatey 90% of TriZetto Facets TM Sybase and Orace appications run on IBM Power Systems providing superior eves of reiabiity, scaabiity, performance and security. High Performance and Reiabiity TriZetto reguary benchmarks its appications so that they scae propery and can support upper tier workoads. In fact, the Facets system recenty satisfied the demands of one of the argest heath pans using a 20-miion member database. TriZetto s customer hosting division has enjoyed over % uptime across neary 170 IBM Power Systems servers over a 9 month period 2 in Robust Soution rchitecture Enhancing Payer-Provider Coaboration The IBM-TriZetto technica soution architecture for payers and providers consists of three appication tiers: 1. Provider tier with porta soutions incuding the dvanced Eigibiity Soution; 2. Point of Service (POS) tier impemented at the payer tier, and 3. Enterprise Web ppication tier impemented at the payer tier. The provider tier requires minima infrastructure for depoyment and works in a standard browser environment with a few key web services and connects to the POS tier at a payer s ocation. The TriZetto Provider POS appication consists of severa additiona high-vaue web services and uses IBM WebSphere ppication Server (WS) running on an IBM Power System or x86 server. This POS tier connects to TriZetto s core enterprise appications tier providing providers and payers with functionaity for more streamined near rea-time business coaboration. PROVIDER CCESS MEMBER CCESS EMPLOYEE CCESS PROVIDER CCESS Websphere Microsoft PROVIDER TIER DVNCED ELIGIBILITY SOLUTION POINT OF SERVER TIER Sybase Orace Microsoft IBM POWER 720 IBM x86 IBM Power 750 pache POS Windows IBM x86 Websphere IBM DS8870 IBM Storwize v7000 Figure 7: Technica rchitecture CUSTOM DEVELOPED SOLUTIONS 3rd PRTY SOLUTIONS ELECTRONIC DT EXCHNGE (EDI) PROVIDER S END PYER S END This third enterprise appications tier consists of four key infrastructure tiers. The web server and appication tiers typicay run on x86 servers. The critica database tier benefits from the reiabiity, performance and security of the IBM Power System running IX. The storage tier, options incude IBM System Storage DS8000 and/or IBM Storwize V7000 storage systems for exampe, provides the inteigent foundation to manage the vast voume of data generated by TriZetto appications. IBM PureFex System integrates and optimizes a compute, storage and networking resources to deiver infrastructure-as-a-service (IaaS) out of the box, thereby providing another patform option for this TriZetto soution. Infrastructure Matters: IBM Workoad Optimized Systems Provide Firm Foundation IBM offers unique high vaue soutions that make it easy to depoy, manage and run TriZetto s enterprise appications with high performance, virtuaization and scaabiity. IBM Power System is an open server patform that optimizes Big Data & naytics performance to maximize business insight in rea-time. In addition to speed, the scae-out economics of the system provide the confidence to move more data-centric appications to the coud with encryption buit into the foundation. With continuous innovation buit into the patform, it removes the constraints imposed by commodity architecture and enabes future integrated hardware soutions that dramaticay acceerate compute and data-intensive tasks. The POWER server heps avoid unpanned downtime, and provides payers and providers unmatched functionaity for more streamined near rea-time business coaboration. IBM PowerVM provides a secure and scaabe server virtuaization environment to contro cost and maximize resources. Chaenges for Payers Payers Must Coaborate Heathcare Soutions 8

9 IBM System Storage portfoio offers robust, high-performing, scaabe systems to meet the needs of heathcare organizations of a sizes. DS 8000 storage systems are designed to manage a broad scope of storage workoads that exist in today s compex data center. Organizations wordwide, incuding many in the heathcare industry, use this fagship IBM disk system for its extraordinary resiiency, scaabiity and performance, as we as for its abiity to address the demanding requirements of the critica data at the heart of busy data centers. Being optimized for arge-scae compex workoads, DS8000 manages the vast voume of data generated by TriZetto appications, heping harness huge amounts of data for greater insight and productivity. dditionay, the storage system s word-cass high avaiabiity and excusive integration with IBM enterprise servers, incuding Power Systems, deiver extraordinary vaue for IT operations. XIV is a high-end disk storage system that everages a unique grid architecture. The system deivers consistent high performance, extreme ease of use and exceent data economics, making it an idea choice for midrange to arge enterprise heathcare organizations. It is idea for coud, with easy provisioning, autonomic data pacement, and simpified management. XIV aso provides high service eves for dynamic, mixed workoads as we as efficient depoyments tapping rich OpenStack, hypervisor and other integrations. Storwize famiy systems deiver innovative, virtuaized storage for software-defined environments and are idea for TriZetto depoyments. vaiabe in a wide range of storage systems to accommodate entry eve to midrange environments, Storwize famiy deivers sophisticated capabiities that are easy to depoy, yet aso hep contro costs for growing businesses. Technoogies that wi boost efficiency incude automated tiering with IBM Easy Tier to optimize high-performing disks and fash storage. nd IBM TM Rea-time Compression can hep store up to 5 times as 3 much data with no appication performance impact. TriZetto chose the IBM StorwizeV7000 for its On-Demand Environment not ony because of its technoogica capabiity: custering, bunded services such as dynamic tiering, FashCopy, thin-provisioning and no-charge host-eve mutipath software, but aso for the cient business needs of: ease of use, rapid depoyment and fexibiity, both for IX (IBM Bade Center) and VMware. - Pete Gi, Senior Technica rchitect, TriZetto. The TriZetto Performance Lab and the separate On Demand Environment (ODE) defined use cases to incude: New customer product orientation Training, demonstrations and appication test-drives Customer-specific pre-production appication configuration Data conversion and vaidation Benchmark and scaabiity testing Product stabiity, reease management and quaity assurance d-hoc projects requiring easticity for rapid spin-up and depoyment IBM fash portfoio incuding the market eading FashSystem famiy, wi drive extreme performance to enabe rea-time business decisions, the efficiency around the data ecosystem, and the resiiency to make the data avaiabe and accessibe. FashSystem famiy incudes richy featured software-defined fash soutions. dditionay IBM aso offers fash-optimized Eastic Storage software, XIV, Storwize V7000 and DS8000 storage to bring greater performance, IBM MicroLatency, efficiency and resiiency to the IT infrastructure. IBM PureFex System is a fuy integrated infrastructure patform that supports a mix of compute (Inte and Power), storage, and networking resources and can be optionay accessibe through the IBM SmartCoud Desktop - a virtua desktop infrastructure (VDI) soution which aows mobie access from anywhere. Heathcare payers and providers can acceerate time-to-vaue with the buit-in broad patterns of expertise and proven guideines in systems management, appications, and hardware maintenance. Smarter Software from IBM Improves giity and Operationa Efficiency With IBM software, payers and providers can further improve business agiity, coaborate more effectivey and impement innovative heathcare business services whie reducing risk, improving security and ensuring compiance. When integrated with IBM systems, these smarter IBM software soutions greaty improve infrastructure reiabiity, performance and scae. Chaenges for Payers Payers Must Coaborate Heathcare Soutions 9

10 IBM WebSphere is a eading integration and appication infrastructure software patform that enabes service oriented architecture (SO) soutions for dynamic, interconnected business processes. TriZetto customers rey on the security, performance, reiabiity, scaabiity and fexibe depoyment options of WebSphere ppication Server to provide their members and empoyees continuous access to their mission critica systems. IBM WebSphere ppication Server on IBM Power Systems provides an exceent patform for server consoidation with continuous avaiabiity - a critica requirement when many providers are supported on the same payer system. IBM Stering Connect:Direct is a security-rich coud infrastructure that heps payers and providers exchange documents more securey with customers and business partners, regardess of size, ocation or communications preferences, through a singe connection. It faciitates rea-time processing not ony with externa business partners, but aso heps gather information and data from disparate sources. Specificay, this comprehensive process visibiity heps payer and provider improve strategic decision-making with accurate, reatime data. It ets them enhance the customers experience through compete audit trai of data movement. For more information To earn more about this IBM Heathcare soution, contact your IBM saes representative or visit: IBM Heathcare Soutions: ibm.com/industries/heathcare TriZetto heathcare soutions: IBM Power Systems: ibm.com/power IBM System Storage: ibm.com/storage IBM PureFex Systems: ibm.com/purefex Footnotes 1 Resuts from piot test of the dvanced Eigibiity Soution with 60 providers in the BueCross BueShied of Tennessee 2 Interna TriZetto measurements, January September, IBM ab measurements, pri Copyright IBM Corporation 2014 IBM, Route 100 Somers, NY U.S.. Produced in the United States of merica Juy 2014 Rights Reserved IBM, the IBM ogo, ibm.com, System x, Power System, IX, System Storage, DS8000, XIV, Storwize, FashSystem, Easy Tier, Rea-time Compression, MicroLatency, PureFex, POWER7, POWER8, PowerVM, WebSphere, Stering Connect:Direct, SmartCoud are trademarks or registered trademarks of Internationa Business Machines Corporation in the United States, other countries, or both. If these and other IBM trademarked terms are marked on their first occurrence in this information with a trademark symbo ( or ), these symbos indicate U.S. registered or common aw trademarks owned by IBM at the time this information was pubished. Such trademarks may aso be registered or common aw trademarks in other countries. current ist of IBM trademarks is avaiabe on the Web at Copyright and trademark information at: ibm.com/ega/copytrade.shtm TriZetto, the TriZetto ogo, TriZetto Provider POS, Facets and QNXT are trademarks or registered trademarks of TriZetto, Inc. Portions of this document are the proprietary property of TriZetto and are provided with permission by TriZetto Corporation. Other product, company or service names may be trademarks or service marks of others. References in this pubication to IBM products or services do not impy that IBM intends to make them avaiabe in a countries in which IBM operates. Pease Recyce Chaenges for Payers Payers Must Coaborate Heathcare Soutions 10