Thursday Jul 31, 2014

IT Modernization, The Key to Success in the Private Health Plan Market in Brazil

Brazil has undergone significant political, economic, and demographic changes over the years, and today faces historic transformation with regard to its healthcare system. While Brazilians have free access to healthcare through a public system – the Unified Health System or the Sistema Único de Saúde – the private healthcare system is growing at a rapid pace.

Kathy McCarthy, Director of Sales Consulting for Oracle Health Insurance, discusses the topic in today’s post:

Individuals are increasingly seeking care in the private sector. Over the next few years, Brazil expects that more than 20 million additional individuals will purchase insurance through a private health plan, bringing the total number of participants in the private system to more than 75 million. This projected growth presents significant opportunity for private health plans, but are they ready?

Brazil’s budding economy, up-and-coming middle class, and progressive policies toward managed care make it a high-growth market, and the public system is struggling to keep pace. The private system, by and large, operates much more efficiently, with shorter waits and quality care. As the population becomes wealthier as the result of economic growth, more Brazilians – approximately 55 million individuals totaling a quarter of the population − are choosing to enter the private healthcare system.

The influx into the private healthcare system opens significant opportunity for Brazil’s health plans. It also presents several challenges:

  • Healthcare payers must deal with regulatory and contractual complexities that are unique to the sector, such as waiting period requirements, co-pays, and the negotiation of in-network versus out-of-network agreements.
  • They must also have the scalability required to process a much higher volume of claims than in life and P&C lines of business.
  • Healthcare payers can expect to handle dozens of claims per member, adding up to tens of millions of claims annually, and they must do so rapidly and cost effectively.
  • Processing these large volumes of transactions can place tremendous strains on payers who continue to adhere to manually intensive systems.

Healthcare payers – which for the most part employ decades-old core technology – have limited business process scalability in a fast growing market, and struggle to keep pace with change. Payers seek greater agility to address their specific business requirements and adapt in real time to ever-shifting market conditions.

By consolidating legacy systems onto a single health insurance-specific platform, payers can support core business processes and emerging opportunities in the private sector, while establishing critical flexibility in their IT infrastructure that increases visibility, reduces operational costs, and drives innovation within the business.

For this reason, Brazilian payers need flexibility as a central IT platform design component. They require applications that support core business processes in Brazil’s increasingly blended public and private systems, in which people may choose a private plan as a supplement to, or in lieu of, public insurance – ultimately supporting business innovation and rapid growth.

Payers need to do three things to be successful:

  • Get Agile - Invest in an IT infrastructure that can respond to the rapidly changing market
  • Amplify Business Intelligence - Business intelligence and analytics will make the difference for payers. It will aid in determining risk, provider effectiveness, fraud, market trends and more
  • Help Members Help Themselves - Employ self service options that make it easy for members to sign up, pay premiums, obtain information

While Brazilian healthcare payers’ challenges are complex as they seek opportunities in a growing market, they are not unique. Oracle Health Insurance is focused on helping healthcare payers around the world with their modernization challenges by providing applications that support payers’ business processes, enabling them to implement changes and provide consumers with tailor-made products while using uniform administrative processing.

Learn more by reading the strategy brief, Prescription for a Healthier Tomorrow: Considerations for Health Plan IT Modernization in Brazil.

The Oracle Health Insurance suite of applications have proven their scalability at customers with sizes ranging from 100,000 to 4,200,000 members (with approximately 10 million product enrollments) in a single instance. In addition, Oracle offers engineered systems or hardware, software, and storage tuned to address specific health insurance challenges including high availability, performance, and scalability.

Don’t forget to keep up with Oracle Insurance year-round:

Tuesday Jul 29, 2014

What Providers Should Consider Before Jumping into the Payer Market

The evolution of ACOs in the market has led to an increase in provider based payer organizations, the addition of some 400 this year require a new level of data sharing and analytics. The ability to analyze impacts of changing payment models and care guidelines on healthcare delivery and payment will define the stability and growth of the integrated organization.

Kathy McCarthy, Director of Sales Consulting for Oracle Health Insurance, discusses the topic in today’s post:

With the ACO model, healthcare organizations will continue to acquire groups and services within a specific demography.  Using integrated analytics to predict the impacts when entering new markets where different services and payment models overlap will be a key for accelerated expansion.

Providers need to consider several criteria before entering the payer market. The provider organizations needs to:

  • Understand the complexity of the market
  • Have clear goals
  • Conduct the necessary research
  • Evaluate delivery systems

Research has shown that there is no correlation between success and market share, location or deep pockets.

Providers need to:

  • Have positive relationships with other health systems in your area.
  • Have existing risk-based contracts with your providers.
  • Look at your market.
  • Have a relationship with a  payer organization

Providers will require systems that can:

  • Respond to rapid changes in policy
  • Merge clinical and financial data
  • Provide quality cost-efficient care
  • Support HIPAA PHI requirements
  • Create new sustainable payment and delivery models

Operational efficiency will be a key to success. Payers will need to have IT and analytics that will play an important role .Being able to merge clinical and financial data will be crucial to success. They need to improve the overall IT efficiency and gain more predictable costs and outcomes.

IT needs providers should consider:

  • Be prepared to implement changes required to improve performance.
  • Need for analytic capabilities.
  • Need for alternate payment arrangements.
  • Need to quickly introduce new plans, support efforts to reduce operating costs and take advantage of the emerging opportunities.
  • Many legacy systems are decades old and require costly and time-consuming hard coding to make even simple changes.
  • Seek and require rules-based systems.
  • Seek new payment models.
  • Provide quality care for a reasonable cost.

Oracle Health Insurance components help address these issues by providing:

  • Rules-based componentized products allow plans the agility and flexibility needed for success.
  • SOA-based components allow plans to purchase solutions that do not require an entire new system.
  • Scalability and reliability are built into all Oracle products.
  • Solutions can be delivered in multiple ways.

Learn more by watching the recent webcast, How to Navigate the Emerging Trend of Providers Shifting Focus to Healthcare Financing.

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Friday Jul 25, 2014

The Case for Stand-alone Rating System

Anton Wiryawan, Insurance Product Strategy Director, discusses the topic below:

Recently, I was at the IASA conference in Indianapolis. Oracle had a large booth with several demo pods, and I was showcasing Oracle Insurance Insbridge Enterprise Rating. An attendee stopped by our booth and had questions about how to decide on a rating solution. His company is looking to modernize their IT infrastructure and one of the systems that they want to replace is the policy administration system. So his question was: do they still need to invest in a stand-alone rating system or can they just use the rating components that come with the new policy admin system?

Historically, carriers have relied on policy admin systems to provide all functions to manage the policy lifecycle from quick quote to application to underwriting to policy issuance and even servicing the policy. Even today, in markets outside North America such as in Europe and Asia, many carriers are still relying on their policy admin systems to handle everything. However, over time, there are vendors that now specialize in one particular function of the policy lifecycle (i.e. rating, underwriting, etc.) and deliver more robust systems to address that one specific need. Now, carriers have more options and need to choose between standalone systems that perform one function very well or one integrated system that offered modules for each function, but with varying degrees of functional depth.

According to Celent through their conversations with many carriers and vendors, the central consideration in choosing best of breed or best of suite is one of architecture. The stand-alone rating solution enables carriers to centralize all product and rating information in one place. Rates can be built once by business users and distributed to any application that needs it. This will position carriers with a more agile business, reduce total cost of ownership, speed time to market and improve distribution management.

Because of the benefits of stand-alone rating solution architecture, many policy admin system providers are now offering their rating functions in a stand-alone manner. So should you buy rating solution from these policy admin vendors? We believe that even though these vendors position their rating as a stand-alone solution, the reality is the rating system is somewhat tied into their policy admin offering, and often customers might need to install some of the policy admin components to make the rating module work. Rating users might be impacted by policy admin system inefficiencies and scalability issues.

A better alternative is to invest in a stand-alone rating solution to achieve the architecture benefits mentioned above from a vendor that built the rating system from the ground up (i.e. not part of the policy admin system). The vendors that provide a true stand-alone rating solution have resources that are dedicated to delivering more advanced features for rating only and not for other policy admin functionality. Using modern technologies, these vendors make their stand-alone rating solution open and more easily integrated to different systems.

If you want to know more about the true standalone rating solution and its benefit, you can download a white paper.

Related Resources

  • White Paper: Stand-Alone Rating Engine: Leading Force Behind Core Transformation Projects in the P&C Market

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Thursday Jul 24, 2014

Core System Selection Process for Mid-Market Insurance Carriers – An unavoidable challenge? Or a great opportunity?

The insurance industry is going through a lot of changes and insurance carriers are looking for new avenues to create a competitive advantage – innovative products, quicker time-to-market, better utilization of customer touch points, etc. Meanwhile the business context has changed both internally and externally. The challenge for the IT organization of a mid-market insurance carrier in this context is to enable such business initiatives while at the same time keeping costs down. The critical and most costly piece of the Insurance IT landscape is their core business systems.

Mid-tier carriers struggle with having the same needs for business agility, process efficiency, and support for a growing portfolio of products as large carriers but with IT budgets that are a fraction those of their larger peers. Typically their core systems consist of inflexible legacy applications cobbled together through a patchwork of brittle system interfaces. Most carriers understand that they must do something about these core systems in order to achieve their business goals, but the challenge is to identify the systems that can achieve their goals at a price they can afford. At first glance, the core system selection process might seem to be a staggering set of challenges but when analyzed carefully, there are quite a number of opportunities a well-selected core system can provide to an Insurance organization.

Considering the challenges first, the typical concerns include: high cost of implementation, speed to market for new products, diverse portfolio of products existing on multiple legacy systems, maintenance overhead of existing legacy systems, manual processes, localization, burden of implementing large systems as well as back office customer service costs and user training. The opportunities that can be addressed through a new core system implementation include: product innovation, new service delivery channels and distribution channel options, rationalization of IT resources and easier regulatory compliance processes.

To mitigate these challenges and address them in the most effective way and to ensure the organization can benefit from these opportunities and get the best benefit from the new core system implementation, the core system and vendor selection criteria should be exhaustive to provide appropriate weights to all these factors. Ideally, the system and vendor selection criteria should be an exhaustive but easy-to-use checklist for the Policy Administration (PAS) and System Implementation (SI) vendors.

For a more detailed look at all the challenges and opportunities and recommendations on setting up the system and vendor selection criteria, you could refer to the strategy brief on “Addressing the Challenges and Opportunities Mid-Market Insurance Carriers face in a Core System Selection Process” in the Oracle Strategy Brief:

To learn more about Oracle Insurance Policy Administration for Life and Annuity and how Oracle’s solutions can benefit mid-market insurers, visit oracle.com/insurance.

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Tuesday Jul 08, 2014

New in DocumakerTech: Integrating Documaker with Web Services

The first post in another multi-post series is live on the Documaker Tech blog: an in-depth look at configuring Documaker and Docupresentment for publishing with web services! The first post in the series discusses web services in general, some technologies used in web services, and presents a step-by-step guide to configuring the solution for publishing with EWPS web services. Future posts in the series will focus on DWS web services, and additional solutions for starting transactions without extract data, and using the composition services. Check out the first post here.

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Oracle's flexible solutions can help insurers navigate the change necessary to meet today’s challenges and have the business agility to be prepared for the future.

For more information, visit oracle.com/insurance.

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