Payer Care Management 2023
How Do Vendors Perform as Use Cases Expand?

Cognizant CareAdvance Enterprise

Product used by health plans of all sizes who have other Cognizant solutions. Seen as comprehensive but complex. Integration is the main attraction for new payers selecting the product—and a challenge for some current customers who feel hesitant about their long-term plans with the solution.

“A different system we reviewed didn’t have the type of services that we were looking for, like care, case, and disease management. Cognizant’s product did offer those things, especially for a certain population within our region. The product is really helpful to us on the business side. Having a disease management piece is extremely important for the population we work with.” —CIO

“The solution was supposed to fully integrate with another one of Cognizant’s products, and it has never functioned that way. We have to go around the integration because we don’t like it. One of our biggest frustrations is the integrations do not work or aren’t customizable to our needs, and it is nearly time to cut our losses.” —CIO

EXL CareRadius Suite

The limited number of interviewed customers say support team is easy to reach and addresses issues quickly. System is highly configurable without much customization needed. Provider-sponsored health plans struggle to integrate with the EMR, and some mention the need for custom code. Some payer customers are considering leaving the product or limiting use cases in the product.

“If we come to EXL with a challenge on our side, whether it is contract modification or something that we need to fix or manage differently, they are very helpful in getting us resources and doing research if needed. They have a very active user group. We can ask them about what their future path is, and if we have something that we want to be considered as a standard, they will put it out to the user group. It is nice to know that our voice is being heard and that the vendor considers usability as a big factor.” —VP/other executive

“CareRadius Suite integrates with other systems almost entirely by us writing custom code for the integration. EXL has batch interfaces that are supposed to make things easier, but we have not found those to be adequate." —Manager

Gainwell Technologies (HMS) Care Management

Product has been acquired multiple times (first from Essette and then, more recently, from HMS). Seen as highly customizable. Some payers have been hesitant to upgrade or are even considering leaving because the product has been changed to be more standardized and less configurable, a notably different direction from how customers have used it in the past.

“We had Essette tailored to our organization, but we recently did an upgrade, and now we use the system as the vendor has it set up. Since we have done that and tapped into all the new capabilities, our performance is way up. The solution is several times faster than before because we don’t have as many custom instances running at the same time.” —COO

“We like Essette CM because we were able to customize it for our business a bit. But HMS Holdings Corp is moving away from that. And that is where we are going to see a drop in the satisfaction. As they are moving forward, their leadership has decided not to support any customized workflows or customizations. So we still have needs there, but HMS Holdings Corp is hesitant to do any work. And if they do any work, the price has quadrupled over the last year. HMS Holdings Corp is making it very well known that if we want to do anything outside of the box, it is going to be very painful.” —Director

HealthEdge GuidingCare

The most widely considered and selected product. Provides good functionality in traditional care management and is also often used for appeals and grievances and a few other emerging use cases. Improvements still needed with integration. User interface can be hard to navigate without good training. Customers describe high involvement from the vendor’s executives and CSM team.

“I am very pleased with the overall functionality and customer service. I appreciate that the tool continues to evolve and improve. Day-to-day operations work well, and when issues occur, they are resolved quickly.” —VP

“Social determinants are a huge factor, especially with the Medicare and Medicaid population, and HealthEdge has some opportunities to improve how that information is visualized. I would like HealthEdge to do something similar to Epic in terms of having a color wheel that shows the different social determinants and ranks them based on different criteria. HealthEdge needs to take complicated information and present it simply and visually. I would also love to see HealthEdge really do some human factors work and look at utilization statistics, such as the consistency of buttons and actions and how many clicks it takes a user to get through a workflow. I want to be able to do things like track workflows by the average time it takes to complete a task and better understand the user experience.” —Clinical informaticist

InfoMC Incedo Care Management

Because of vendor leadership turnover, customers report improved executive involvement. Product seen as strong in supporting behavioral health use cases; can provide combined view of data from behavioral health and clinical sides. Expanding into broader care management use cases. Still needs some development (e.g., EDI for better integration to eliminate workarounds).

“The CEO has always recognized and appreciated our business and has always made sure that we aren’t just pushed aside. With some of the leadership that the vendor had in the past, I didn’t feel that we were being heard. The leadership team that InfoMC has had now for the last couple of years is probably the best, strongest, and most customer-focused team that I have ever seen. The team has stepped up and taken care of a lot of things that we have asked for. I guess the previous leadership started a contract with an offshore company for staff augmentation, and we didn’t see much of a difference from that, but this new leadership team has really embraced it. We are seeing higher quality products delivered to us. We are seeing a more responsive turnaround time.” —Director

“We didn’t buy an out-of-the-box product; we knew there was a lot of development in this and a lot of work to be done together. But there was a fair number of workarounds where we had to retrain staff. We had to close some loops where staff could get around a working algorithm because it is really important that we do care management consistently and in a standardized way and do not take away the personalization piece of individual member care when doing core requirements. There were areas over time where we found gaps when staff members were able to filter through the cracks and do care management in their own special way, and that would then throw off reporting, making it difficult to ensure that we were meeting our objectives.” —VP/other executive

Medecision Aerial for Payer Care Management

Multiple recent leadership changes have impacted customer satisfaction and led to inconsistent, slow-to-respond support. Some lost their regular point of contact. System needs better claims integration, reporting, and workflow management. Newer customers are more satisfied and report better integration.

“We built some one-off workflows with the vendor in order to get things through quickly and get information into our members’ hands. We want things to be centralized, and the vendor was able to help us get information back from their platform, pipe it into our platform, and move those to our members in near real time. There are automated workflow rules that will trigger events for case managers to reach out or that will trigger letters or other types of communication. We have standard visibility into the whole intent process.” —Manager

“We use Medecision for all of our population health programs, including member-facing programs for case management, condition management, and the transition of care. To be honest, I am pretty negative. Medecision has a new CEO every year, and we have a new person every year. Medecision is very slow to respond to the industry. Their platforms and reporting are okay, but they don’t take client feedback. They had client forums for a while where we would all submit types of enhancements. It takes six months to a year to get one small change in an assessment. The system’s reporting is not very good.” —VP/other executive

MHK (MedHOK) CareProminence

Limited number of interviewed customers are satisfied and consider the vendor a true partner. Product seen as particularly good for meeting CMS compliance, as customers see the vendor leadership providing expertise on services with CMS Medicare and Medicaid programs. Some hope to see further improvement in user interface, reporting, and breadth of use cases (e.g., population health management, NCQA preparation).

“We really like that MHK’s president, Marc Ryan, comes from a compliance space. There are some areas where users have to give up a little control to work with MHK because of MHK’s commitment to compliance with Medicare. However, we think that that is totally worth it. When we were doing our RFI, we wanted a vendor who could help us with compliance and who had the ability to produce what we wanted. MHK was unique. Their platform came configured with the format that we wanted. Within a short amount of time, we were able to produce certain reports. We couldn’t do that with any other systems. The vendors we looked at were pretty similar in terms of utilization management and care management. They also had a lot of the same abilities.” —COO

“MHK’s system struggles a little bit with the NCQA side of things because it is very fluid and state specific. The vendor is less fluent in case management than in other areas as they have fewer clients in that area. The pharmacy side of the product doesn’t work as advertised, specifically the medication therapy management feature. I don’t know whether that is because we didn’t go with the out-of-the-box solution or because the person promoting the product didn’t know how to explain it correctly. We decided to go with a different vendor for the case management piece. The system doesn’t do well with customizations. If the client doesn’t keep up with the upgrades, the customizations will never work as advertised.” —Director

UpHealth SyntraNet

Relatively new to the payer care management market. The limited number of customer respondents have very complex environments and report functionality gaps; solution not seen as mature. Expertise is noted as another opportunity for improvement, as customers feel expertise is lacking in terms of how utilization management keeps up with regulatory changes. Customers have mixed future outlooks for the product.

“My overall satisfaction with the product will go up over the next twelve months. The solution has potential, and the vendor is working on it. Right now, it has a lot of glitches. However, I see its potential to meet our needs. I have no doubts about the product.” —Manager

“UpHealth doesn’t have a core understanding of utilization management and what that core functionality should be. So we were teaching them about that as they went along. They have had trouble understanding the pace of change in government-sponsored insurance requirements. They are used to building something and not having to constantly be updating it at the pace that is required. There have been challenges with the vendor’s communication around enhancements and other things.” —VP/other executives

VirtualHealth HELIOS

Over last few years, vendor has been less considered but has still attracted new wins; overall performance has declined. The limited number of customers respondents want better QA for updates and proactive help from the vendor with resulting bugs. Resources reportedly stretched thin, hurting implementations, delivery, and support.

“HELIOS as a product is generally good. It operates well and is very reliable. VirtualHealth has good intentions and a good vision. During HELIOS’ implementation, we did a lot of good, close work with VirtualHealth, and with the continuous improvements afterward, a lot of activity was going on.” —VP/other executive

“The issue is we are struggling to get implementations done on time because VirtualHealth keeps losing people. They are understaffed and can’t keep project managers or developers. Other IT and venture capital firms keep stealing VirtualHealth’s people. The IT space is a dogfight right now.” —CMO

ZeOmega Jiva

Vendor is 2023 Best in KLAS winner for payer care management and is seen as a partner that fosters great relationships. Helps payers solve issues and provides customizations to meet client needs (though customizations may cost extra). Seen as expensive, though support for a wide range of use cases contributes to more convenient, unified workflows. Not considered easy to use, and customers want fewer clicks. Can be less effective as an out-of-the-box solution.

"What is super nice about the solution is that all of the parts for care management, appeals, and utilization management are all on the same database and the same platform. For example, if we are doing a utilization management review on a member, we may have denied a service because it is not coming in as medically necessary. If the member has an appeal against that, we can see everything that has happened with that member from case management to utilization management. We can create the appeal and attach that and really have a full record of everything that is going on across the care management spectrum. One of the things we really like about the solution is that all of our teams for medical management, utilization management, case management, care management, pharmacy, medical, or quality management appeals are all on the same database and are working with that member as an individual unique member across all of those episodes of care.” —Director

“Whenever we have to do custom work with the vendor, it is fairly expensive and takes us a while to get off the ground. All the nickel-and-diming and adding on of costs gets a little annoying. Initially, the vendor was very flexible in contracting and negotiating, but now that we are live on the product and want to add things, we feel like we are nickel-and-dimed. Everything is an extra cost. In my eyes, there are hidden fees because we didn’t know about them in advance.” —CIO

Zyter (Casenet) TruCare

Amid multi-year performance slide, customers report vendor executives have recommitted to improve. Broad use cases supported. Upgrades often delayed and buggy. Some larger plans see increased efficiency, while others struggle with basic functionalities not working.

”The vendor has been honest since day one. Since the first time they answered an RFI, I haven’t gotten a lot of smoke. I haven’t gotten vaporware. I have gotten honesty. The vendor has kept their word. They show up when there are challenges, and in fact, they more than show up. They address issues that are their fault. And when we are having problems, they roll their sleeves up and help us. We cannot put a high enough price tag on those things. The vendor has given us bad news at times on promises they can’t keep, but they tell us about those things so that there are no surprises. The whole idea of being a vendor partner is how they went into this relationship. Even when we did negotiations, when we came out of negotiations, we wished everybody we did business with were as fair as Casenet. They were tough, but they were fair. And our relationship has been like that since the beginning.” —CMIO

“There have been a lot of issues with some upgrades and hotfixes from Casenet being delayed numerous times, and we still don’t have those yet. There were lots of bugs with our last upgrade that significantly affected us, so we had to implement lots of workarounds to make sure that nothing failed in terms of timeliness. The bugs created a lot of extra manual work for us. Even with previous upgrades, they have never been able to help us very much. The vendor has never been very successful when we have paid them to do a guided upgrade.” —Director