Payer & Payvider Research

Over time, care management vendors have developed new functionalities that have allowed payer organizations to move beyond traditional use cases (e.g., case management and utilization management) into emerging use cases (e.g., behavioral health, automated prior authorization). Care management solutions are in an already low-performing market with persistent integration and functionality challenges, and with these emerging use cases, customers have a renewed need for strong engagement and support from vendors. This report examines which vendors are providing strong customer relationships, delivering innovative product functionality, and facilitating adoption and long-term customer loyalty.

Inpatient treatment for high-risk cardiovascular patients comes with a significant cost for patients, providers, and payers. Costs are lower and outcomes are better when the care for these patients is effectively managed outside the hospital. To achieve this, the collaborators in this case study combined payer and provider data to better predict costs and patient outcomes and then established a bundled payment contract that reduces the costs of caring for patients with high-risk cardiovascular diseases while ensuring they receive the care appropriate for their condition. Outcomes include reduced hospitalization and lower costs.

Vulnerable and underserved populations face a variety of barriers that can make it difficult for them to adhere to their prescribed medication regimens, and the impacts of non-adherence—in terms of health outcomes and costs—can be severe. Low medication adherence was a particular problem for the healthcare organization in this case study, whose patient population covers one of the most vulnerable and underserved zip codes in the country. To encourage better adherence among high-risk individuals, this organization collaborated with a payer organization and value-based care partner to identify patients in need of additional support and help resolve their barriers to adherence. Results include better health outcomes and higher CMS Star ratings.

Strategies employed by payers, provider-sponsored health plans, and provider organizations are starting to become more proactive, and the need for solutions with prospective, predictive capabilities is rising. Additionally, amid rising healthcare costs and economic uncertainty, organizations are looking for solutions that deliver more for less. This report examines risk adjustment vendors’ abilities to drive outcomes and value, their prospective capabilities, and their offerings’ ease of use.

Inefficient care transitions lead to wasted time and energy, increased risk of human error, and potentially poor experiences for both patients and providers. Despite the industry’s attempts to ensure the right information is sent to the right people at the right time, healthcare organizations must often revert to manual processes for data entry, verification, and communication. Some organizations use or want to use technology to streamline their transitions of care (TOC). This report—KLAS’ first to look at TOC—draws from the perspectives of 95 healthcare leaders across multiple care settings to understand their adoption of care transition technology, the challenges they encounter in their care settings, and the vendors they are considering.

CMS recently issued a new regulation stipulating that CMS-regulated payers must be able to securely store and share patient data under the HL7 FHIR standard. To achieve this, organizations use CMS payer interoperability products, which usually provide capabilities such as patient access APIs, provider directory APIs, and payer-to-payer data exchange. Health plans and state agencies are evaluating how well technology vendors’ existing or newly developed solutions can help them stay compliant with the new CMS requirements. This report is KLAS’ first to validate the purchase decisions and customer experience of some of the vendors in this area.

<p style="margin-top: 10px; background-color:#77945b; padding:15px; color:#ffffff;">In January 2021, Optum announced their intentions to acquire Change Healthcare. The merger remains unfinalized, however, as the US Department of Justice blocked the deal in February 2022 due to anticompetition concerns—such a merger would give UnitedHealth Group, Optum’s parent company and the nation’s largest insurer, access to rivals’ sensitive data. The legal proceeding is ongoing and scheduled to go to trial August 1, 2022. This report shares Optum and Change Healthcare customers’ reactions to the merger and their perceptions of its impact. Between March 2021 and April 2022, KLAS interviewed 48 individuals from 46 unique organizations; of these respondents, 9% are Optum customers, 56% are Change Healthcare customers, and 35% are customers of both vendors.</p>

In 2021, new CMS rules came into effect that require CMS-regulated health plans to have a patient access API and a provider directory API. Aimed at increasing the interoperability of personal health data, these rules have prompted payers to look at new ways of sharing external information. This report evaluates 1upHealth‘s FHIR Platform, an interoperability solution designed to help payer customers meet governmental regulations and improve consent and authorization management.

Business process as a service (BPaaS) is a new delivery method for core payer claims and administration solutions that can lighten administrative burdens and increase health plans’ efficiency. Cognizant began offering BPaaS about two years ago (previously offered business management services [BMS] and business process outsourcing [BPO]). Today they have the largest presence in this space, and they actively encourage BPaaS adoption. For this report, KLAS performed in-depth interviews with five organizations using Cognizant’s Healthcare BPaaS model for Facets and QNXT (both acquired from TriZetto).

Though core administration platforms are essential for payer organizations, many of the products in the market are perceived as outdated, complex, and low performing (the market has one of the lowest average performance scores of any KLAS measures). However, HealthEdge has recently seen increased attention from both small and large health plans, who view the vendor’s technology as innovative and who have been asking KLAS for vendor insights. This report examines the experience of HealthEdge customers and how the HealthEdge technology stands out from competitors’.

Along with buzzwords like “AI” and “population health,” the term “digital front door” has become more popular but lacks a consensual definition. For this study, KLAS spoke to 27 leading organizations to understand what digital front door means to them, what digital front door strategies and key technologies they use, and what outcomes they have seen. Based on the lessons they have learned along the way, these organizations (most of which use Cerner or Epic for their core EMR) also shared advice for peers seeking to build or improve their digital front door strategies.

Analytics and risk adjustment are hot topics due to the expenses associated with value-based care, government regulations, and CMS programs. Pareto Intelligence’s revenue integrity solution attempts to provide organizations with actionable data to improve their risk documentation outcomes. This report examines the Pareto customer experience.

In the past, payers have struggled with vendors’ care management solutions not keeping pace with functionality and support needs. Recent market shifts, such as M&amp;A activity and leadership and ownership changes, along with the need for better payer/provider collaboration have created energy and optimism around the future of some vendors. Which vendors are stepping up, and which are missing the mark? This report focuses on how well vendors are helping organizations achieve desired outcomes through delivery of needed technology, excellent support and service, and follow-through on promises.

The initial explosive growth of ACOs sparked by the Affordable Care Act has since tapered off due to uncertainty about how to move into downside risk. Over the years, several services firms have emerged to help provider organizations with the setup and ongoing management of ACOs. This report shares client feedback on how effectively and quickly these firms drive clinical and financial impact and prepare clients to take on more risk.

Vatica Health provides dedicated clinical support and technology to payers’ contracted physicians to improve diagnostic coding, documentation, and quality of care for members. Vatica Health’s team works on-site to lend providers support, enabling payers to manage members and their care while also increasing financial impact and reducing compliance risk.

In 2021, new CMS rules came into effect requiring CMS-regulated health plans to have a patient access API and a provider directory API. These regulations, aimed at increasing the interoperability of personal health data, have prompted payers to look at new ways of facilitating external information sharing. This report offers a first look at Smile CDR, a fast-moving, healthcare-specific solution provider that has recently delivered interoperability solutions to payer customers to help meet the new mandates.

Provider organizations have begun to consistently ask who, if anyone, can be a one-stop shop for patient engagement—allowing organizations to consolidate vendors and create a unified patient experience. Directed by the voices of provider and vendor executives, along with patients themselves, KLAS has helped the industry define “patient engagement platforms” through a series of reports and summits. This report is a culmination of those efforts, intended to help provider organizations understand who they can turn to for all (or almost all) of their patient engagement needs. Included in this study are insights from 153 of the broadest-adopting customers across 33 vendors.

MedeAnalytics offers a cloud-based analytics platform designed to help healthcare providers and payers make data-based decisions. Provider organizations utilize MedeAnalytics’ SaaS solutions for patient access, revenue integrity, business office, and value-based care, while payers use them for employer reporting and healthcare economics.

In early 2020, KLAS published our first look at digital fax solutions. That report examined satisfaction feedback from the most advanced users of four digital fax solutions. Data for several other vendors, including Updox, was too limited to be shared at that time. However, additional advanced Updox customers have since been interviewed, and this addendum examines their customer experience.

A core administration platform is the transactional heart of a payer organization—it is used to enroll new members, process and pay claims, and manage product lines and benefits. Many of the products in this market, while needed and typically stable, have been around for decades and are highly customized, hosted on-premises, and often seen as old and complex. Many payers are therefore reluctant to replace these systems because the risks and required effort are so high.<br /><br />But recent buying activity suggests the payer core administration platform market is seeing revitalization. Triggered by the opportunities and challenges of payment reform and value-based care, payers are looking ahead and starting to bid for new vendor partners. <br /><br />KLAS spoke with 30 payer organizations who are making or have recently made purchase decisions, and they shared their candid feedback and insights regarding what vendors they have considered, selected, and/or replaced. These interviews reveal new energy and life in a market long overdue for change—in terms of both product and service delivery. 

In recent years, provider organizations have increased their investment in patient engagement technologies, but the outcomes they report are often provider-centric and don’t necessarily benefit patients directly. It is becoming increasingly important for the patient voice to be at the center of vendor development and provider deployment efforts. To help support this focus, KLAS surveyed over 300 patients, asking them which patient engagement technologies have been most impactful to them and how they expect these technologies to impact them in the future.

On November 11–12, 2019, healthcare IT leaders (20 from healthcare organizations and 19 from vendor organizations) gathered in Park City, Utah, to help guide the healthcare industry toward a common patient engagement target. The goal of this summit was two-fold: (1) to share success stories and recommendations for overcoming barriers and (2) to define what a patient engagement platform should entail.

Despite reduced regulatory pressure, competitive and financial factors continue to drive organizations toward value-based care (VBC), yet making the transition is a complex and expensive undertaking, especially for smaller or midsize organizations, who may lack the resources and expertise of their larger peers. An array of services firms and software vendors offer managed services designed to help. These offerings vary widely, and provider organizations will want to consider several factors when choosing the firm that is right for them. This report examines eight services firms and software vendors who offer VBC managed services to examine the types of projects and organizations they work with and how well they perform.

Transitioning from fee-for-service to value-based care (VBC) is a top-of-mind concern for healthcare organizations. However, <u><a href="/report/healthcare-management-consulting-2018-who-can-help-with-healthcare-s-biggest-challenges-an-executive-perspective/1278" data-id="1278" data-itemtypeid="7">previous KLAS research</a></u> has revealed that VBC transformation is also the area in which healthcare executives are least familiar with which firms are well positioned to help. This report examines nine firms that provide value-based care consulting services to explore the types of work these firms do (and for who), how consistently the firms perform across clients, the outcomes they deliver, and the factors that drive these outcomes.

<p>While utilization management and care management solutions have been around for decades, today health plans are looking for modern technology solutions to help them manage multiple business lines and adapt to changing requirements for value-based care. While innovation overall in payer HIT is not abundant, KLAS has seen an increase in decision energy mostly from relatively or completely new vendors receiving stronger consideration than existing or established vendors.</p><p>KLAS defines payer care management solutions as systems comprising functionality in areas like utilization management, case management, disease management, and care coordination. 40 unique payer organizations shared insights with KLAS about their purchasing decision process, including which vendors they considered, selected, and decided to replace. As validated in this research, future-state goals (noted below) are becoming increasingly important in these decisions.</p>

Demand for payer IT consulting services continues to rise as changing market regulations have increased the need for improved efficiency, accurate software, and ways to navigate the complex market environment. This report, KLAS’ first in the market, offers transparency into what payer IT consulting firms offer and their performance, including expertise and adaptability to customer needs (i.e., being flexible in approach and staffing and agile in making changes). At a high level, healthcare-specific firms are delivering more guidance and flexibility than cross-industry firms, though there are exceptions to this trend. 

Providers’ demand for effective patient engagement (PE) solutions continues to grow, as does the number of HIT vendors claiming to meet those needs. But which vendors are meeting needs today, and which are likely to play meaningful roles tomorrow? KLAS asked providers to name HIT vendors they are currently using or considering for future use: 74 organizations mentioned 109 unique vendor names. In an effort to make sense of all the options, this report is the first to apply a patient engagement–specific framework developed through the collaboration of leading provider and vendor executives at the KLAS Keystone Summit in October 2018.

The Best in KLAS designation is reserved for vendor solutions that lead those software and services market segments that have the broadest operational and clinical impact on healthcare organizations. These vendors earn the title of Best in KLAS—a recognition of their outstanding efforts to help healthcare professionals deliver better patient care. Separate from the winners of Best in KLAS, Category Leaders also earn top honors for helping healthcare professionals provide better patient care. The Category Leader designation is reserved for vendor solutions that lead select market segments in which at least two products meet a minimum level of KLAS Konfidence.

The primary goals of this perception report will be to identify management consulting firms who can help meet healthcare executives needs not only now, but in the future as well. We will highlight the breadth of their capabilities and the depth of their healthcare expertise. Additionally, we will uncover the emerging consulting needs of providers and the attributes they value in a consulting firm.

When purchasing a population health management (PHM) solution, provider organizations can choose from three general types of vendors, each of which comes with a potential disadvantage. Organizations can (1) choose from the established vendors, who tend to have lower overall customer satisfaction; (2) start with their EMR vendor, though EMR solutions can be immature and lack the required functionality depth; or (3) select an upstart company—though their potential can be alluring, these vendors lack a proven track record. In a rapidly evolving market where few vendors deliver as much as they promise, what are the best options available? Which PHM vendors have high market consideration, above-average customer retention, or high customer satisfaction? And do any vendors have all three? 

Ever-evolving HEDIS metrics continue to demand payer attention, but annual quality reporting alone is not an effective way to close care gaps or reduce costs. Health plans have repeatedly expressed a need for more frequent HEDIS reporting and deeper analytics capabilities that enable them to empower proactive care interventions and improve outcomes for their members. KLAS asked 84 health plans which vendors go beyond the required HEDIS check boxes to help clients forecast risk and improve quality.

Patient engagement is as old as medicine, but the use of information technology to engage patients is just taking shape. Broad visions and experimentation abound, but there is a lack of consensus regarding end goals, and pathways are still being cleared. Resources needed to move forward are scarce with investments largely being dedicated to the most obvious of tactical, departmental business cases. To help provide transparency into these industry trends and HIT vendor performance, KLAS has published an ongoing series of reports on the effectiveness of patient engagement solutions and quality of vendor relationships. This whitepaper represents a high-level summary of findings from three comprehensive annual reports published in 2015, 2016, and 2017 to provide insight on the status, progress, and direction of patient engagement technology.

The need for partners is stronger now than it has ever been as healthcare organizations continue their journey to provide seamless care across the continuum, shift from fee-for-service to fee-for-value, reduce costs, and ultimately improve patient care. KLAS has published numerous reports on a wide range of consulting services, but this is the first that focuses on which firms healthcare organizations consider true partners. KLAS interviewed decision makers from 246 healthcare organizations about the consulting and services firms they have used to discover which they consider true partners and which they would avoid using again.

The need for patient engagement is as old as medicine, but the use of information technology to engage patients is in its adolescence. Today, broad visions and experimentation exist, but there is a lack of consensus regarding end goals, and pathways are unclear. Resources to fuel progress are often in short supply, with most investments limited to the most obvious business cases, often at the departmental level. By asking provider organizations how they currently use solutions from major HIT vendors, this report takes a break from ideals to examine where the rubber truly meets the road of patient engagement: Why do organizations invest in certain vendor solutions? Where are vendors helping across a spectrum of patient engagement needs? Which vendors are most impactful and why?

With healthcare costs at unsustainable levels, the industry finds itself on a trajectory from fee-for-service to value-based care. Provider organizations who aren’t prepared to manage cost and take on risk while also maintaining or improving quality will have a hard time surviving. In this first-time report, KLAS takes an early look at the various ways organizations that already have a strategy are tackling this challenge and what vendors they are using or considering to help them. Interviews were conducted mainly with C-level executives, mostly from organizations with 500+ beds. Only the strategies and vendors most commonly brought up in interviews are discussed below.

This first-time KLAS report takes an early look at the vendor solutions used for health insurance exchanges and insurance enrollment in the ACA market. Faced with the uncertainty, political instability, and complex regulation that characterize the ACA market today, healthcare payers are searching for vendors who can help them successfully weather the storm. Based on interviews with healthcare payer executives, this KLAS report gives initial but important insight into how well—or poorly—some of the key solution vendors are meeting needs.

Many health plans today are faced with rapidly changing regulations combined with middle-of-the-road performance from their core claims and administration vendors. Citing poor service and support, old technology, and nickel-and-diming, these health plans are looking for improved innovation and the ability to quickly adapt to industry changes.

Getting patients engaged in their own healthcare has tremendous potential to benefit patients, providers, and payers in terms of both quality and cost. HIT vendors offer a variety of options to help accomplish the task, but most providers’ engagement efforts are not yet significantly impacting patient health. This report examines the patient engagement landscape and highlights the early successes of those providers and vendors whose strategic approaches to patient engagement are making a difference.

The opportunity for customer relationship management (CRM) to have a meaningful impact in healthcare is growing. However, managing relationships with current and prospective patients and physicians often requires new workflows and access to consumer data not typically tracked in healthcare today. Even as this nascent market is still being defined, many vendors claim to help in a myriad of ways. This report will explain which of the most common niches vendors are being used in as well as help providers understand their peers’ current overall satisfaction with vendors’ technology and service.

New market demands are pushing health systems to take on more risk, resulting in some starting their own health plans. These provider-owned health plans (“payviders”) and other full-risk-bearing organizations like them rely on vendor solutions for core payer functions, yet many of the platforms are decades old. How well do these solutions perform, and will new entrants shake up this reemerging market?

Once more of a concept than a reality, sincere patient engagement efforts aim for patient collaboration in order to manage health, promote wellness, and lower costs. The door is open for vendors to market a number of products, but how are providers prioritizing their patient engagement strategies? Which vendors and technologies are they really counting on? With the help of 143 providers, this report seeks to clarify today’s patient engagement landscape and offers the following definition: Patient engagement is improving the wellness of patients by using enabling technologies that empower patients to take responsibility for, understand, and report on their adherence to collaborative plans of care.