From back office to center stage: A new paradigm for healthcare payor operations

Published: November 2, 2016

Executive summary

Consumer empowerment, integration of healthcare delivery, and new technologies are driving a radical transformation across the healthcare ecosystem. Over the next decade, market forces will compel payors to exchange today's compartmentalized structures for flexible operations, horizontally integrated processes, and analytics capabilities that serve the evolving needs of members and providers.

To thrive in this new environment, payors need to embrace a new model for the future, one that redefines payor operations as the entire set of interactions with both consumers and providers and the end-to-end processes that support and engage them. To build and maintain these connections, they must invest in three transformation imperatives: expand their operations footprint horizontally across the payor value stream; become analytics driven; and leverage a distributed ecosystem and operating model.

Chief operating officers who see around the corner — and respond proactively to these market forces — can differentiate their organizations, deliver far greater value to consumers and providers, and operate much more effectively and profitably.

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Delivering new capabilities

Industry trends are placing intense pressure on payor organizations to transform their operations by integrating the end-to-end processes that support and engage both consumers and providers. New operating models are emerging that expand service operations beyond the back office, leverage new analytical insights and information pathways, include new incentives and rewards, and build strategic partnerships across a distributed ecosystem. To build the optimal model, executives should define a clear vision and goals for future operations — where and how they want to participate in an increasingly consumer-centered healthcare market. They should then determine what capabilities and tools they need to enable their vision. These skills may include care management capabilities tailored to different member and provider segments, and expanded enterprise-wide reporting and analytics to support proactive member and provider services. By finding the optimal operations model, and determining the path to achieve it, payors can stay a step ahead of change and meet the many challenges of consumer empowerment and integrated delivery.

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From back office to center stage: A new paradigm for healthcare payor operations