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Payer Care Management 2019 Payer Care Management 2019
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Payer Care Management 2019
Decision Insights Report

author - Doug Tolley
Doug Tolley
author - Jennifer Hickenlooper
Jennifer Hickenlooper
author - Sam Eaquinto
Sam Eaquinto
August 14, 2019 | Read Time: 10  minutes

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.

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.

focus areas within payer care management

Lesser-Known AssureCare and VirtualHealth Capture New Attention

Among vendors considered for new decisions, VirtualHealth stands out to healthcare organizations as being a newer company and for having a user-friendly product. AssureCare, which has been around longer, is seen among interested payers as having a robust, scalable product.

payer care management purchase decisions

Consideration Energy Highest for ZeOmega; Altruista Health & HMS Essette Making Inroads

ZeOmega and Cognizant lead in overall considerations from health plans making new decisions in care management, with existing market presence driving consideration of Cognizant and product robustness driving energy for ZeOmega.

Medecision’s long history and large customer base garner visibility for them. Payers considering Altruista Health report involvement from vendor leadership as a factor in their decision. Casenet is considered largely due to their positive reputation and robust medical management capabilities. Energy driving HMS Essette considerations comes from what payers describe as vendor flexibility to make contract terms work. Those looking at MHK often talk about benefits like integration with compliance functionality and capabilities.

market presence vs new consideration energy

Household Name Medecision Sees Most Potential Replacements

Medecision is the vendor most often mentioned as potentially being replaced. These replacements are not only for the legacy AxisPoint product but also for the go-forward Aerial product. Most often, dissatisfaction with Medecision is based on poor relationships, lack of vision or strategy communicated to the customer, and weak support.

where are medecision axispoint and aerial customers going

Post-Purchase Satisfaction: Changes on the Horizon?

Casenet leads in overall satisfaction, but scores have been declining due to some missed expectations. Payers using Cognizant often use their broader platform but struggle with care management specifically. Clients of VirtualHealth (limited data) describe a tight-knit relationship and excellent support. ZeOmega customers give their vendor good marks for strong integration.

overall score distribution of customers (after purchase)

Market Segment–Specific Reasons for Considering, Not Considering, & Replacing

Functionality is the main reason why potential buyers consider a care management solution. The most common functionality components mentioned are reporting, templates, and stratification tools, followed by the flexibility to create user-defined tools and fields. Vendors who provide robust reporting functionality and system personalization have more considerations than their competitors.

A lack of functionality also leads potential customers to not select certain vendors. The most common types of functionality mentioned include reporting and analytics—specifically, patient-centric reporting for case management, planning, and assessment. A few payers mentioned passing over solutions because of missing appeals and grievance functionality, and a few mentioned utilization management functionality being absent or not robust enough.

Generally, replacements are driven by challenges with missing functionality that an organization feels they need and lack of integration with all the pieces needed to support comprehensive care management. A poor experience with support or lack of innovation from the vendor also lead to dissatisfaction and drive replacement energy for about one-quarter of decisions.

reasons for selecting, not selecting, or replacing

Vendor Options with 3+ Considerations

alturista health

A relatively newer player in the market, Altruista Health is often considered for their strong functionality and company culture. Similar to ZeOmega, Altruista Health stands out with high interest from organizations looking at a fresh solution. Multiple respondents describe Altruista Health as an innovative company with a different approach from their competitors. Others voiced concerns about the vendor’s size and bandwidth to handle the needs of larger payers. Altruista Health was considered in 23% of validated new purchase decisions, though performance data on the vendor is still too limited to be shared.

“We looked at the business functionality and the technical functionality, and then we looked at the implementation process. . . . We thoroughly vetted Altruista Health’s ability to do the integration work and to have flexibility. They have a consistent product that we can use to have reproducibility and the ability to learn inside the system.” —VP/CMO


Organizations selecting AssureCare tend to be very large, have complex needs, and have a distinct, long-term vision for care management. While AssureCare is only considered in 10% of new decisions validated by KLAS, respondents see the vendor as competent. AssureCare is also a relatively new entrant in the care management space. Payer organizations select them for their combination of robust functionality and strong partnering. Performance data on the vendor is still too limited to be shared.

“We really wanted to partner with a vendor that had the patient at the center of their focus. We don't necessarily look for vendors. We look for partners that align with our vision and collaborate on how to solve problems. AssureCare's leadership teams really fit that model. When we have a problem, we don't have to point fingers and wonder how to solve it. We all roll up our sleeves and figure out the problem together. AssureCare wants to transform healthcare in the world, so we partnered with them. They are great partners.” —CIO


Considered in one-quarter of new decisions, Casenet is noted for having a good reputation and strong product functionality (specifically in medication management and reporting). Product demonstrations are seen as slick, but more than one respondent complained about unkept promises and feeling that the sales team oversold the system. While Casenet has been the performance leader in payer care management for the past three years, overall client satisfaction has been slowly declining due in part to overpromising and underdelivering, which organizations considering a purchase are starting to notice.

“I know that some other Casenet clients have had to do workarounds because of certain functionality that turned out to be missing. I don't feel that Casenet has actually given us everything they sold to us. They are a better vendor than most, but we are still in a difficult spot because of them.” —CMO


Cognizant has a built-in mindshare advantage over other vendors because of their very large customer base using their core claims platform, so they are often considered when customers look at implementing a care management system. Cognizant was considered in 30% of validated new-purchase decisions. Respondents cite deep functionality as a strength of the system. Organizations who did not choose or are replacing Cognizant feel that the solution lacks innovation and seems old and that the vendor is slow to develop new technology.

“We have struggled with Cognizant's process for enhancement requests. I think that Cognizant attempts to listen to their clients when feedback is being given, but Cognizant is slow to change pace. I think that their system could have additional capabilities that would allow it to be more agile with the rules and logic.” —VP of Utilization Management


HealthEdge is seen as an up-and-comer in core claims, but they are not considered in many new decisions specific to care management (considered in 13% of validated decisions). When HealthEdge is considered, it is often in conjunction with their core claims system. Overall, reasons for consideration vary. One organization replacing HealthEdge feels the product is out of date, and another does not feel Cognizant stood behind their product.

“We decided to move away from HealthEdge for a couple of reasons. The system had a lot of clicks, and the case managers felt that the system couldn't think ahead. They wanted a system with built-in logic and the ability to text out information, send standardized letters, and produce reports. With HealthEdge CareManager, we had to build our own letter templates, which weren't clean. Our new tool will include standard letters.” —Business Office Manager


HMS, a large payer vendor known for their payment integrity solutions, acquired Essette in 2016 to expand their portfolio. HMS Essette was considered in 20% of validated purchase decisions in the last two years and is often selected when considered. HMS Essette seems to be a good fit for smaller health plans that want to take advantage of the product’s flexibility and functionality without breaking the bank. Some organizations who did not choose the vendor felt the solution was missing critical functionality, such as CMS-related accreditation requirements.

“We went with Essette because they had great technology and were very open in terms of what they could and could not do. I liked that fact that they were moving towards an integrated model, so we were able to integrate with multiple systems. Being able to integrate with EHRs that we already had in our company was very important. Essette was open to making changes and adapting to what we needed. Also, their financial model was very attractive.” —Business Office Director


With three different care management products, Medecision has the largest market presence. Aerial is their go-forward product and is considered often because of Medecision’s reputation for being a good partner. Several clients are looking to move away from Medecision products including Aerial, CCMS, and VITAL, citing a poor service experience and problems rooted in overcustomization. Organizations consider Medecision for complex needs and use cases but sometimes struggle when Medecision doesn’t meet those complex needs well. Current customer satisfaction with Aerial is mixed; some clients report high satisfaction, while others are very dissatisfied. Concerns include product issues, and almost 30% of interviewed current customers would not buy Aerial again.

“Part of the problem with Aerial is that when we implemented the solution, we customized it too much and entangled it with some of our other systems. After that, our hands became tied in terms of how we customized the system further. Medecision is not as responsive as we would like them to be. . . . We had another issue that we wanted to solve, and it took Medecision several months to get a statement of work to fix it.” —VP of Administration


With a background in compliance and claims, MHK (previous MedHOK, renamed after their acquisition by Hearst Health) has carved out a niche in care management by way of the pharmacy. MHK was considered in 18% of validated decisions, with organizations citing broad functionality as a primary reason. Others who did not select the system feel the workflow is not ideal. MHK receives a good number of considerations relative to their market footprint.

“We wanted to use one system to do all approvals and denials, and we had to find a system that would really handle both utilization management with our clinical team from the pharmacy, UM Universe, and case management, as well as our appeals and grievances. MedHOK offered what we needed. The final voting was done by our IT and clinical teams. People were impressed with the platforms. They were impressed with the fact that the MedHOK tool was integrated for both UM Universe as well as appeals and grievances, and they liked the MedHOK staff.” —VP Information Technology


VirtualHealth, a new player in the payer care management space, is highly recommended by clients who feel the company is very customer-centric. While the number of considerations of VirtualHealth is middling, respondents who consider them feel they are a strong option and often select them. Current customers feel VirtualHealth is a committed partner who will hold the organization’s hand when necessary. Early performance data from a small but growing customer base indicates most payer customers are satisfied, though some clients have had functionality hiccups.

“We needed to find something that was very modern in design. We did financial, viability, and technical reviews. We ended up selecting VirtualHealth’s product in that process. It was an elegant, subtle platform from a user interface perspective. Architecturally, I liked VirtualHealth’s product. I thought the vendor might suffer a little bit in the functional comparisons with the business because they were a newer player, but our decision was unanimous. I have a hard time imagining someone not choosing HELIOS. There were risks that came along with our decision, but the risks were outweighed by the benefits.” —VP of Utilization Management


ZeOmega has the highest consideration rate of all measured vendors in the payer care management space and is gaining real traction; they are considered in about one-third of all validated decisions from the past two years. System flexibility and robust functionality are cited as reasons to consider ZeOmega. Some potential buyers felt the product was too expensive. Most current customers are satisfied and point to the product’s scalability across business lines. A few mention concerns about how well ZeOmega will continue to support clients while growing quickly.

“ZeOmega's product is a lot more flexible than other products that we have worked with. The vendor has invested a lot towards where the market is going in terms of population health management and other sorts of things surrounding the tool." —CEO


Decision Insights help provider organizations understand which vendors have market energy and why other organizations are considering these vendors. Decision Insights are not designed to be a comprehensive census or win/loss market share study.

author - Natalie Jamison
Natalie Jamison
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This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price. Please see the KLAS DATA USE POLICY for information regarding use of this report. © 2024 KLAS Research, LLC. All Rights Reserved. NOTE: Performance scores may change significantly when including newly interviewed provider organizations, especially when added to a smaller sample size like in emerging markets with a small number of live clients. The findings presented are not meant to be conclusive data for an entire client base.