Value-based care (i.e. accountable care, population health, pay for outcomes, etc.) will eventually become the industry norm, but for now, organizations face the daunting challenge of preparing for the new operating models while remaining profitable in the current pay for service environment.
Key challenges payer executives are facing:
|Managing Profound Change||
|Creating a More Agile Organization||
|Creating New Consumer and Retail Oriented Capabilities||
|Securing and Growing Market Share||
|Containing Core Operating Costs||
DCG's healthcare practice can help payers assess their strategy, develop a roadmap to execute key initiatives and help manage the implementation of the roadmap to reduce execution risk.
Contact us to discuss how we can help your business achieve a higher level of performance.
See how we've helped our clients achieve their goals. Contact us to discuss how we can help your business achieve a higher level of performance. To see more click on one of the Case Studies below:
- A Health Care Payer organization was undergoing a $100M+ business model transformation. Executive leadership had significant concerns regarding the effort's success and limited visibility into its status, timeline, and controls.
- DCG was engaged to perform a delivery and risk assessment to evaluate the overall status of the project, identify areas for improved delivery, and make recommendations to increase the likelihood of success.
- DCG performed a rapid 3-week assessment using the DCG Risk Assessment Framework
- DCG performed 40+ interviews and reviewed key program artifacts
- DCG used gathered information to identify key risks and develop associated recommendations and a remediation plan
- The main assessment themes included:
- Implementation Management
- PMO Organization & Function
- Program Governance
- Program Planning & Resource Management
- Other Risk Factors
- Developed structured approach to improving project controls and evaluating and communicating project status
- Developed heat map depicting the project's immediate risk areas
- Developed recommendations addressing:
- Communication and Engagement
- Master Plan
- PMO Structure
- Program Resources
- Program Status
- Technical Risk
- Transformational Goals
DCG brought a structured methodology that allowed, using 24 of its sub-components, for the evaluation of the project's health and the identification of improvement recommendations. The client adopted DCG's recommendations improving its project governance, planning, resource management, and reporting processes and procedures. By implementing these recommendations, the client achieved a timely, successful program go-live.
- DCG was tasked with improving the organizational alignment and structure of how provider network pricing is managed and maintained using Lean Six Sigma methods.
- The current state provider pricing organization was spread across multiple departments, which resulted in frequent hand-offs, no accountability, and a lack of control of the end-to-end process.
- The objective of the project was to enable effective future state processes, this included defining a new organizational structure, roles and responsibilities
- The scope consisted of the following activities:
- Develop current and future state process flows, organizational structure, and system diagrams
- Develop an implementation plan for the future state organizational structure
- Define operational metrics and dashboard to measure the end-to-end process performance
- Improved first time accuracy of provider pricing by identifying critical data elements required at each step in the process
- Reduced provider inquiries / complaints due to issues with accuracy and timeliness of pricing data
- Defined the end-to-end, integrated provider pricing process
- Established metrics and a governance structure to monitor end-to-end performance
- Established clear roles and responsibilities for all staff involved in the process, reduced redundancies
- Created clear accountability for each aspect of process performance dashboard
DCG performed a thorough assessment of the end-to-end provider enrollment and pricing processes. The insights gained from this analysis paved the way for an organizational redesign that increased accountability, accuracy, and the ability to measure process performance.
- A Health Care Payer wanted to improve its ability to manage and evaluate the delivery of its informatics department. With limited communication and reporting, there wasn't an enterprise understanding of, and visibility into, work being delivered by the department.
- DCG was engaged to clarify and document the operating model of the department and implement structure to support ongoing evaluation of both departmental and individual performance.
- The overall objective was to define high-level processes and then derive value added metrics to measure performance and quality
- The scope consisted of the following activities:
- Assess current-state operating model and recommend enhancements
- Define performance and quality metrics
- Implement leadership and management dashboards
- Develop processes to manage dashboards
- Implement enhancements to request fulfillment process
- Well documented processes for data capture, metric development and communication
- Enhanced communication between informatics staff and its customers
- Improved responsiveness to customer feedback
- Improved visibility into performance via new reporting dashboard
- Enhanced leadership visibility and understanding of the operational effectiveness of the department
DCG successfully implemented both leadership and management dashboards for ongoing performance tracking and evaluation. Through the project, the client was able to clearly articulate the value produced by the informatics department and improve its overall delivery approach.
- A Health Care Payer did not have a dedicate operations unit. Operational processes were distributed across several different organizations, making them very difficult to manage and improve.
- DCG was engaged to develop a new operations framework for the client to utilize when managing its operations.
- The client wanted to manage its operations activities as 3 main end-to-end processes:
- Manage enrollment & billing
- Administer benefits & process claims
- Manage member interactions
- The scope consisted of the following activities:
- Assess current-state process scope
- Define operations strategy and goals
- Develop an operations framework
- Define end-to-end performance metrics
- Document implementation risks
- Developed organizational goals that aligned to the organization's mission and provided a foundation to define SMART metrics
- Developed a framework that helped the client manage operations as a cohesive unit while still being organizationally separate
- Defined governance activities that supported meeting the objectives of the operations organization
- Defined metrics that provided a view of process outcomes, quality and performance
The new operations framework and metrics improved communications among operations processes/departments. It also provided the operations team with the ability to both measure performance and implement a coordinated response to findings.
- DCG was contracted to develop and implement processes for a payer’s new Revenue Management Risk Adjustment Program.
- DCG led a team of process modelers and business subject matter experts to prepare the Medicare Advantage and Commercial business for the changes needed by the payer’s new Revenue Management Risk Adjustment Program.
This project involved:
- Strategic analysis of the underlying health-reform drivers and opportunities / threats for our client
- Documentation of business and technical requirements
- Impact analysis to identify operational risks and the required business readiness activities for the impacted departments
- IT program management, testing coordination, and user rollout support / business readiness
- Organizational design (including process maps, organizational charts, and HR / recruiting support)
- Engaged various departments and business owners to create alignment for the project changes
- Developed process flows to capture Medicare Advantage current state and leveraged these to develop Commercial future state processes
- Engaged with IT delivery leads to provide input into Medicare Advantage current state processes and potential changes that might occur in the Commercial business
- Defined a new business unit including org chart, process maps, and staffing model
- Implemented an entire new business unit
DCG enabled the payer's implementation of the needed changes to support the new Revenue Management Risk Adjustment systems and processes - changes were done in a timely manner and with minimal disruption to the business.
- A Health Care Payer was attempting to implement a new Care Management System (CMS). This system was to be used by providers to request authorizations and by client staff to perform Utilization Management, Case Management, and Disease Management. Prior to engaging DCG, the client had experienced many delays and had suffered higher than expected project costs.
- To address missed go-live dates and resource constraints, DCG was engaged to coordinate the business readiness activities using a structured project management approach.
- DCG was engaged to prepare the business for a new CMS through go-live and post go-live stabilization
- The project approach consisted of all the activities needed to prepare the business to use the new CMS including:
- Project risk assessment
- Project planning and management
- End-user training planning, scheduling and delivery
- User acceptability testing (UAT) planning & management
- Cut-over planning and execution
- Post go-live support
- Increased effectiveness and performance of project team
- Structured project approach that improved communication and risk identification / mitigation
- Effectively planned, managed and executed 400 UAT scripts to confirm the readiness of the new CMS solution
- Successful cut-over strategy developed and executed with virtually no downtime for end-users and provider community
- Successfully prepared, delivered and managed cut-over communications to 600 end-users and 12,000 providers
- Successfully managed the delivery of training to 600 end-users
DCG brought a structured methodology that ensured not only that the new CMS would meet business needs but also ensured over 600 end-users and 12,000 providers were prepared and supported throughout the implementation.
- A large health management organization (HMO) wanted to improve its STARS score in the area of smoking cessation and have more PCPs provide smoking cessation counseling to patients.
- DCG was engaged to manage the development of a new wellness program to accomplish these objectives.
- The project consisted of developing a communications strategy and gathering data to help target additional communications to improve the wellness of smokers and the plan's STARS score
- The communications strategy was two fold - direct to members and through PCPs
- The project consisted of:
- Project planning
- Developing a communications strategy
- Developing surveys and other data collection tools
- Analyzing member responses
- Adjusting communications strategy
- DCG assisted in managing the project and providing recommendations
- The team created four different communications to improve member awareness of available smoking cessation resources
- Successfully met the survey response metric, with members returning 50,000 surveys in electronic and in paper format
- The project team collected and analyzed the survey responses and was able to adjust the communications for the next year
The project was completed on time and on budget, successfully achieving the defined success criteria and improving the client's smoking cessation wellness program.
- A Health Care Payer replaced its care management system (CMS) and required a governance model to manage system changes and ongoing maintenance. Prior to the project, the CMS management activities were impacted by poor communication, coordination, planning and unclear business requirements.
- DCG was engaged to define and implement a set of governance processes that would ensure the business was adequately engaged in the review, prioritization and planning of the CMS change management activities.
- To facilitate requirements management of the current CMS and future changes, DCG was also engaged to develop a complete business requirements document and requirements trace matrix.
- The governance activities required for the business to manage the CMS consisted of the following:
- Issue Management
- Change Management
- Requirements Management
- Portfolio Management
- Continuous Process Improvement
- Measurement and Reporting
- Increased understanding of CMS issues, their impact to the business, their priority for resolution and the time / resources required to address them
- Enhanced cross-functional coordination and planning (e.g. business, IT, configuration unit and the vendor)
- Reduced risk of knowledge loss by documenting all current requirements and tracing those requirements to the existing test cases
- Improved testing, training and implementation management by formalizing business engagement and readiness activities as part of the CMS change management activities
DCG documented business requirements and implemented a business governance model for the new Care Management System. Upon implementation, business engagement within CMS management was improved through explicitly defined system change ownership and accountability. Clearly defined and actively managed requirements allowed the client to realize an enhanced prioritization process and better planned, tested, and implemented system changes.