Want True Transparency from a Core Administration Partner? Three Questions to Ask.

July 22, 2021 Michael Miller

From cherry-picked data to major problems swept under the rug, lack of transparency in a core administration partner can undermine a health plan's success. 

For many health plans, the prospect of delegating key administrative or clinical functions to an external partner has an undeniable allure. Clunky legacy systems and archaic processes that have kept the plan sputtering along like old jalopies for years can finally be traded in for sleek, efficient and scalable solutions that a trusted partner can run at top speeds and efficiencies. 

Yet, there is always that one big hang-up that gives pause to many health plan executives considering the switch to a Business Process-as-a-Service (BPaaS) model: feared loss of control and visibility. Can they hand over responsibility without losing sight of how their plan is operating? Will they know when things are not going well, and will they find out before the inevitable molehill becomes a mountainous problem? Are controls in place to ensure appropriate privacy and security of patient protected health information (PHI) so that the health plan can rest assured that the BPaaS partner is not jeopardizing PHI and the health plan's reputation?

These are well-founded concerns. I have spoken with myriad jaded health plan leaders who were kept in the dark for too long by a vendor while their plans suffered—inaccurate claims, call center mismanagement, poor or inaccurate reports, sagging member and provider satisfaction scores, to name several points of contention. When they do get information, they worry that it's been cherry-picked or inaccurately portrayed to avoid making their client look bad, or sometimes even to avoid costly SLA penalties.

To avoid such scenarios, health plans need to ensure they find a truly strategic partner, who is unflinchingly committed to transparency and not just telling their clients what they hope to hear.

Potential partners will, of course, claim that they are an open book. After all, who would admit that they sometimes hide their hand or withhold bad news to protect their own best interests? But transparency is not solely a function of interpersonal qualities or company culture. It is the result of deliberate decisions about how the health plan and strategic partner work together, and these decisions can set the stage for future business success…or failure.

Here are three questions that a health plan can ask to gauge whether a current or prospective core administration and clinical partner believes in transparency, or if they are keeping that proverbial "black curtain" closed.

1. Does Your Health Plan Have Visibility into Daily Operations of its BPaaS Partner?

Getting help for your health plan does not have to mean you hand over the keys and take the back seat. A strategic BPaaS partner provides the engine, fuel and maintenance, but the plan should keep its grip on the steering wheel.

That is easy to say but hard to do, and even harder to find a willing partner. Thus, plans need an unfiltered view of their operations so they know what is working and what needs attention, then quickly course-correct—TOGETHER. The right BPaaS partner can facilitate this situational awareness by deliberately integrating the plan's own specialists into decision-making. At Evolent, we do this with our unique Client-Centered Operating Model, in which our team works side by side with their health plan counterparts.

By design, the plans we serve have visibility and insights into day-to-day operations of Evolent teams. For example, a health plan chief medical officer might join weekly meetings with clinical leaders to review performance—how many people entered care management, how many care gaps were found, etc. The plan's chief operating officer might sit in on a weekly meeting with teams that review SLA performance and troubleshoot other problems. We avoid thinking of "us" and "them"—we're in it together. One plus one can indeed equal three.

This structure encourages openness and transparency, rather than hiding problems and pointing fingers or trying to put a bandage on a ruptured artery. Issues are assessed and tackled promptly to minimize further problems. Proactive trumps reactive every time.

2. Will the Health Plan Have Access to Raw Clinical, Operational and Administrative Data?

When organizations outsource key operations, they often need to look beyond the dashboards and canned reports that most vendors typically provide. These snapshots are important, of course, but the health plan may want to drill down into these numbers to understand what is really driving their results. They may also want to query raw rata for a variety of analyses, such as trends in utilization. Having an additional set of expert eyes on the data adds a layer of quality control and encourages accountability.

Such investigations require unfettered access to the partner's data warehouse or a feed from that warehouse—both of which are off-limits to most companies. That is not the case with Evolent. Being transparent means being vulnerable and accountable, and some companies are simply not comfortable with that. However, providing such access (in compliance with HIPAA and other applicable state privacy and security laws, of course) should be a non-negotiable cornerstone of your BPaaS relationship when trusting so much of your plan's success to someone else.

A health plan's data is their data, not the partner's. Should the relationship dissolve, that data stays with the plan. Surprisingly, this is not always the case; but Evolent believes that is the only way to do business.

3. Is the Partner Aligned Around the Same Goals as the Health Plan?

At first glance this question might not seem like a valid test of transparency. However, the contractual relationship between a health plan and its partner has profound impacts on what motivates the partner to optimally support the plan and how much information is shared.

The greatest transparency will occur in well-structured BPaaS agreements whereby the strategic partner is working toward the same goals as your plan. For example, if your plan's pharmacy benefit management program wants to increase its Medicare Stars rating for medication adherence, the agreement can spell out those goals and any financial incentives (or penalties) attached to achieving (or missing) them. The BPaaS partner needs to share relevant information and work closely with your plan's leaders to reach these common objectives. In this atmosphere of trust, if the partner identifies a solution that may help you reach those goals, they readily share this information and should not withhold it.

Unfortunately, such symbiotic "win-win" relationships are not a given in typically strict vendor partner-health plan arrangements. Vendors are often incentivized to increase sales into your plan, not necessarily to help meet your plan's goals. Your faith in a partner can be shaken when they aggregate your data with that of other health plans and then sell off the analyses or build new solutions from the data—which you would need to purchase. Are they withholding actionable information today that could benefit your plan in the interest of commoditizing your data down the road? Will these new products or services truly advance your plan's goals, or are they padding the vendor's revenues?  

In this common yet dysfunctional model, the vendor's work finding these opportunities happens out of sight, eroding trust and undermining the health plan's success. 

The Bottom Line

Outsourcing parts of your health plan to a strategic BPaaS partner is a decision that should be built on trust: trust in transparency, trust in expertise and trust in accountability. This type of partnership will keep the plan in the driver's seat and navigating the best route. With a committed and transparent partner, plans can tap into sophisticated solutions and industry-leading expertise while continuing to steer the plan's overall success.

About the Author

Michael Miller

Michael Miller is chief sales officer with Evolent Health Services who has more than 27 years of experience in the health care industry. He is responsible for driving short- and long-term growth through business development, marketing, strategy and product innovation. Before joining Evolent, Michael held various leadership positions at GE Medical Systems, TriZetto/Cognizant and WebMD. He is a native of Denver, Colo., where he lives with his wife and three children.

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