Thursday May 07, 2015

Webcast with FierceHealthPayer: The Changing World of Value Based Payments

The emergence of value-based contracting models represent an evolution in clinical and payment methodologies aimed at creating better quality outcomes, greater provider accountability, and improving cost efficiency. In this webcast we will examine the shift from fee for service to value based payments. Some of the issues being discussed are:

  • How the transitions to value based payments are being accomplished
  • Where are the success stories
  • How the new models of capitation are different from capitation of old
  • Integrating accountability into value-based payment models

We will also examine the technology needed to accomplish these payments, what types of systems/models are suited to this new paradigm and how can this technology be delivered to your organization. We will also discuss where and how cloud technology can fit into your transition.

Join us for the webcast:

  • Tuesday, May 19, 2015
  • 1:00 pm EDT / 10:00 am PDT
  • Register now

Thursday Jan 08, 2015

Core Technology Platform for Health System of the Future

With healthcare costs rising annually over last decade, health reform is at the forefront of many developed and emerging market countries. In many developing nations, the focus of reform is around business models that have more involvement from private sector, while the focus of the reform in the United States is on business models that incent providers to cut costs while improving quality.

However health reform is in its infancy globally, and there is constant change expected over next several years as governments experiment with various business models. Under those circumstances, there is need for a new genre of technology options to cater to the health system of the future. Current inflexible platforms, and even the newer flexible platforms that require health plans to rip-and-replace entire core operational systems, aren’t going to work for emerging health plan needs. Health insurers need to consider “progressive transformation” approach where there is a phased approach to overall end-to-end core systems transformation.  Additionally, insures need to look at options that provide value-based payment support and that work in parallel with their current core processing systems.

Oracle Health Insurance (OHI) business unit within Oracle is dedicated to address the needs of the global health insurance market. The OHI Claims solution was first introduced in 1994 in the Netherlands to cater to the needs of the Dutch market. Today, over 50% of the health insurers in Netherlands run their core operations on Oracle Health Insurance solutions, with many achieving over 98% auto adjudication on claims processing. Furthermore, OHI applications have now been successfully deployed in the United States and other international markets.

The OHI team has spent the last couple of years on developing a technology platform for the newer and emerging health insurance business models.  As a team, we are working with governmental institutions and private companies to understand and help these organizations with their transformation projects. Given our origin in Netherlands, we routinely host health officials and delegations from the emerging market countries considering health transformation to study the Dutch system.

Based on those leanings, we are starting blog series to explore different aspects of the health reform as it impacts health insurance organizations.  We will present business transformation imperatives one at a time and explore technology options to support this. We encourage you to start by downloading our new white paper Building the Healthcare System of the Future. It lays the groundwork for some of the topics we’ll be discussing in the blog series, such as:

  • Driving Transparency with Benefit Adjudication
  • End of Fee for Service? Gaining Popularity of Shared Saving Plans
  • Engaging with Health Providers in Future
  • Real-time Claims Adjudication to Enhance Member and Provider Service
  • Technology Platform for Health Insurance Exchanges
  • Administering Government Programs in a Cost-effective Way

At the end of the series, we will summarize all of the imperatives ahnd present a holistic platform for the health system of future.

Learn More at Oracle Industry Connect in Washington, DC, March 25-26, 2015

Oracle Industry Connect is a premier conference designed to promote innovation and transformation through open and provocative discussion within the Financial Services and Insurance communities. The event brings together top business and IT executives from leading financial institutions including healthcare payers, insurers and banks. Join your industry peers for in-depth discussions on trends, challenges and opportunities facing healthcare payers and insurers today.

Check Back for New Posts

We hope to create a lively discussion throughout this blog series.  Please participate with your comments and thoughts as it will enrich the experience as we embark on this transformational journey of Healthcare Reform.

Please check back soon for our next post. In the meantime, you can keep up with Oracle Insurance year-round via social media.

Wednesday Sep 17, 2014

The Need to Shift to Oracle Health Insurance Alternative Reimbursement

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

The healthcare system is dramatically changing within the United States – both out of necessity and want.  In the current economy, the US spending on healthcare is more than any other nation, more even than this country can sustain.  With the fastest rate of growth compared to any other nation on gross domestic product, the US does not have the best action plan to solving this dilemma. Consumers are left with higher costs and decreased attention to their care, when the focus should be primarily on their well-being. 

The Affordable Care Act (ACA) is putting consumers back in charge of their health by requiring the government to ensure that payers improve outcomes, lower cost and increase access to care.  This application of value-based reimbursement will have four plans that will be implemented by 2015.

  • Physicians in group practices of 100 or more who participate in Fee-for-Service Medicare will be subject to the value modifier in 2015, based on their performance in calendar year 2013.
  • Physicians in group practices of 10 or more provider who participate in Fee-for-Service Medicare will be subject to the value modifier in 2016, based on their performance in calendar year 2014
  • For 2015 and 2016, the value modifier does not apply to groups of physicians in which any of the group practice’s physicians participate in the Medicare Shared Savings Program, Pioneer ACOs, or the Comprehensive Primary Care Initiative.
  • The value modifier starting in 2017 will affect all physicians who participate in Fee-for-Service Medicare.

The value-based payment models are aligned with better outcomes for the consumers and the healthcare providers are forced to work more closely with their patients.

  • Capitation payment is managed by care organizations to control the cost of healthcare.  The fixed amount of money per time period is determined on age, how many individuals and services provided in the geographical area. 
  • Shared Savings Program is services established for Medicare and Medicaid (CMS). This program simplifies communication among providers to improve and ensure optimal healthcare for those using CMS. 
  • Pay for Performance is an incentive payment used to improve the quality of healthcare through a collaboration of measuring the overall care of the patient, resources used and other factors.
  • Bundle Payment is a single payment made to providers or healthcare facilities based on treatments and conditions given.  This method was designed to focus on improved care that providers have clear metric to follow in order to maximize their payments.
  • Fee-for-Service is a specific reimbursement for an individual service done to a patient. Payment is based on formula and funding levels by what the consumer wants to pay, the cost of service and type of service provided.

As a result, healthcare payers need to have better access to data, tools, efforts and a significant increase in time to carry out the implemented models. Therefore, there will be an emerging need for payers to have agile and open systems to meet the new market demand.  Data will need to be merged by payers, in order to provide crucial information that will accurately determine payment.

As the models change so will the need for flexibility and delivery methods.  Cloud-based solutions that have insight, agility and operational efficiency will be the game changers. The Oracle Health Insurance Alternative Reimbursement solution supports a wide range of models that formalizes and automates data. Oracle Health Insurance holds accountable details for contracts, products, providers and members to create financial messages.

To learn more, download and read the white paper, Emerging Healthcare Value-based Payment Models for Improving Patient Outcomes and Cost Efficiency.

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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.

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Monday Jun 16, 2014

Healthcare Payers Need Agility and Flexibility to Implement Medicare Changes for 2015

Since the Affordable Care Act was passed in 2010, Medicare Advantage premiums have fallen by 10 percent and enrollment has increased by nearly 33 percent.  Today, enrollment in Medicare Advantage is approximately 15 million beneficiaries. Over half of these beneficiaries are enrolled in a four star or greater plan, which improves their access to care as well as the quality of care they receive.

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

Many Changes Are in the Cards for Medicare Advantage Plans in 2015

The change in Stars ratings is significant. Plans receiving fewer than 4 stars will no longer be eligible for bonus payments.  Bonus payments for 4 and 5 star plans will be reduced. This can result in the loss of revenue for affected plans. Insurers need to look for new ways to reduce costs to account for the revenue shortfall. This can include anything from lowering administrative costs to improving quality of care.
Some other changes include:

  • Changes in payment models, capitation rates and reconciliation calculations
  • Changes to  out-of-pocket drug spending amounts
  • Improved notification for beneficiaries regarding changes in Medicare Advantage plan networks
  • Greater protection for beneficiaries:
    • Improved access to preferred cost-sharing
    • Improved coordination of care

Payers must act quickly and decisively to implement changes required to improve performance, whether boosting quality, outcomes, operational efficiency, or profitability. As such, healthcare payers should seek greater agility – including in their IT systems, which support modern enterprises. Specifically, they require the ability to quickly introduce new plans as well as support efforts to reduce operating costs and take advantage of emerging opportunities.
As a means to control TCO, healthcare payers are also looking to leverage engineered systems – solutions that combine hardware and software optimized to work together. In addition, many seek more open as well as scalable solutions that can cost effectively expand to meet changing requirements.

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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


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