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Payer Core Administration Platforms 2020 Payer Core Administration Platforms 2020
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Payer Core Administration Platforms 2020
New Decisions & New Life (A Decision Insights Report)

author - Joe VanDeGraaff
Author
Joe VanDeGraaff
author - Sam Eaquinto
Author
Sam Eaquinto
 
May 20, 2020 | Read Time: 18  minutes

Current Time Inside Cache Tag Helper: 5/21/2022 12:22:59 AM and Model.reportId = 1450

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.

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. 

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. 

HtmlReportContent Current Time Inside Cache Tag Helper: 5/21/2022 12:22:59 AM and Model.reportId= 1450 and Model.HtmlReportContent_LastWriteTimeUtcInTicks=637693159667795528

INDUSTRY INSIGHTS & CONTEXT

industry go-forward needs & capabilities

About This Report

The data in this report comes from research interviews conducted with payers in the United States, including standalone payer organizations and payers that operate as part of a health system. Two types of data contribute to the insights in this report: (1) Decision Insights data, which is based on perceptions, feedback, and experiences related to payers’ software purchase decisions; and (2) ongoing satisfaction ratings from current customers, used for additional context. This data covers decisions and considerations over a two-year period, up until the beginning of 2020. The vendors included in this research are Advantasure, Cognizant, Conduent (HSP), Epic, HealthEdge, Mphasis (Eldorado), Oracle, PLEXIS Healthcare Systems, RAM Technologies, SS&C Health (DST), and Virence Health (now part of athenahealth). KLAS validated 30 purchase decisions. The fact that these purchases represent only a subset of the total purchases being made in the payer market is notable since replacement of core administration platforms is uncommon.

iconNote: KLAS Decision Insights data does not represent a comprehensive census or win/loss market share study. Rather, it is intended to help organizations understand which vendors have market energy and why.

EXECUTIVE INSIGHTS & RESEARCH FINDINGS

HealthEdge Clear Leader in Recent New Wins 

In the 30 payer core administration platform purchase decisions KLAS tracked for this research, HealthEdge was by far the most commonly chosen vendor; had HealthEdge shared a list of new customers with KLAS, this number would likely be much higher. HealthEdge is particularly appealing to small to midsize health plans. Payers who chose HealthEdge describe the platform’s architecture as flexible and modern, with rules that enable users to configure benefit plans and products fit for the value-based care world. Some clients express concern that amid a wave of growth for HealthEdge, the vendor is being stretched thin and doesn’t have enough bench strength. Well-known vendor Oracle has a new (though not well-known) product offering. Considerations of Oracle are currently very limited in number; one respondent described the product as “beautiful” but ultimately did not select it because of worries about being an early adopter.

estimated vendor market share vs validated new wins

Market Share Leader Cognizant Nearly Always Considered but Less Frequently Selected 

new opportunity consideration rate vs validated new winsMost purchase decisions for a core administration platform include consideration of Cognizant because of the vendor’s high existing market share. However, a low percentage of those considerations result in selections. Payers share concerns about high cost and difficulty working with the vendor. Payers in this research who selected Cognizant say the vendor has become more involved in user groups and more receptive to feedback; they also feel the product is scalable. When payers consider Cognizant, they typically consider a variety of other vendors as well—unsurprising given Cognizant’s presence in health plans of all sizes. RAM Technologies (focused on Medicare Advantage) and the new Javelina product from Mphasis (Eldorado) are also often considered, but no new purchases of either vendor were validated. The relatively small number of payers who considered PLEXIS Healthcare Systems often selected the vendor; they typically did not consider many other vendors aside from PLEXIS and Cognizant. Reasons cited for PLEXIS wins include an appealing price and the vendor’s relationships with government entities.

Replacements of SS&C Health (DST) Heat Up; At-Risk Advantasure Starts to Turn the Ship

vendors being replacedPayers using DST, acquired by SS&C Health in 2018, have been considering moving away from the vendor for several years, viewing the technology as stagnant and outdated. The SS&C acquisition triggered new client concerns and questions regarding the vendor’s product road map and healthcare focus in coming years. This uncertainty, combined with existing client complaints about poor support, has accelerated migration plans for many. Today, half of interviewed SS&C Health (DST) clients are now actively planning to move to a new vendor. Advantasure clients, while not replacing at nearly the same rate, have also struggled, citing unkept promises through multiple vendor leadership changes as well as insufficient development of new technology. However, several payers have signed with Advantasure in recent years because of the vendor’s new service-delivery models and concerted focus on government programs.

Despite Performance Decline, Conduent (HSP) Clients Optimistic about Future; Epic Grows among Provider-Owned Health Plans 

Since Conduent (a multi-year Best in KLAS winner) acquired Health Solutions Plus (HSP), the platform’s overall score, though not poor by market standards, has dropped—in the last year, customers have seen less engagement from executives and slower support response times. However, clients still express optimism about the future amid new service-delivery models and promises for a web-based product. The primary decision driver cited by organizations that have recently purchased Conduent is the platform’s current capabilities and clients’ expectations for a good vendor relationship. KLAS has yet to validate the customer experience with the vendor’s new product and service models. Epic’s scope and market focus are very different from most vendors’ in this market: their payer customer base is limited to provider-sponsored health plans. Organizations considering and selecting Epic’s core administration platform already have the vendor’s EMR, and integration is their most common purchase driver. Sometimes it is even the health system owner driving the decision, not the payer organization. Tapestry can be a good choice for organizations already using Epic, but it is not available to (and therefore not considered by) standalone payers.

new opportunity consideration rate vs high energy/positive commentary from current clients

More Replacements on the Horizon, Including Virence Health

Nearly half of all health plans interviewed for this research indicate they are (a) considering replacing their core administration platform vendor or (b) dissatisfied but stuck with their current solution. Amid this troubling environment for payers, KLAS expects more vendor replacements on the horizon. Virence Health (formerly GE Healthcare) is particularly vulnerable. Their small customer base of primarily managed care organizations receives reasonably good support but does not expect the dated product will take them into the future. With the exception of HealthEdge, every vendor with more than five validated live customers is at some risk of replacement, with one or more (sometimes many) customers wanting to leave. This suggests unprecedented opportunity for vendors who can step up to deliver both innovative technology and a satisfactory customer experience.

current clients: overall satisfaction vs part of long term plans

VENDOR PROFILES

Vendors below (in the chart and in vendor profiles) are ordered by how often they are considered (high to low).

estimated vendor market share 2018–2019
cognizant logo

With the largest customer base in the core administration platform market, Cognizant is the most established vendor and the most often considered in purchase decisions. However, their selection rate (percentage of the time they are chosen when considered) is the lowest of any measured vendor. High cost, multiple leadership changes, and some uncertainty about future product direction are key factors that keep payers from moving forward with Cognizant. The vast majority of current customers plan to stay with Cognizant despite complaints about not getting their money’s worth; few feel that moving to a different platform would be worth the cost and disruption. Among some current clients, KLAS has validated new product capabilities and development (e.g., compliance capabilities, dashboards, and new hosting models); whether they are driving new purchases remains to be seen.

“Facets is a good product, and it is much better than the product we have had for a long time. One reason why we went with Facets was that there were a lot of plans on the product related to our organization. Our plan is to put new lines of business on Facets. However, one thing about Cognizant that is hard for us is that they want to lock us into things. Cognizant is much more challenging to deal with than other smaller vendors. Their cost structure is not appealing and leaves us with a bad feeling. I know a lot of other organizations feel the same way. Cognizant is trying to lock in revenue, and they are very difficult to work with from a legal perspective. They need to become easier to do business with.” —VP, selected Cognizant

“Cognizant invited a couple of us to their conference for QNXT, which looks like a solution that could be good for us. The product is high on my list. It is really too early to tell which solution we are leaning toward, though. We are provider owned, and the providers are not going to want to spend millions and millions of dollars on something so that we can do exactly what we are already doing.” —IT Manager, considered but did not select Cognizant

healthedge logo

HealthEdge is seen as a disruptor in the core administration platform market and has generated the most new interest and energy. Payers who select HealthEdge often cite the vendor’s new technology and modern system architecture as contributing factors. HealthEdge has won a uniquely high number of new customers in the last several years. Most of those validated by KLAS have been small to midsize organizations, but some larger organizations have begun considering and selecting the vendor. Among these larger potential clients, scalability is a concern but not a proven issue today. While nearly all payers who select HealthEdge express excitement about their decision, some new customers are uneasy about HealthEdge being overstretched by rapid growth. In April 2020, investment firm Blackstone acquired HealthEdge. The vendor’s current estimated market share is midsize.

“HealthEdge blew people away. The system is incredibly intuitive. The vendor demonstrated some of our more complex scenarios in a very simple manner. The system really appealed to us. HealthEdge’s technology was clearly better than the other systems we looked at. Other vendors understood the industry more, while HealthEdge was just a technology company. That has created some challenges because we don’t have a partner with expertise.” —VP, selected HealthEdge

“I would characterize our relationship with HealthEdge as improving. I wouldn’t give our relationship a very high rating. That has to do with a very poor original contract. We have improved that contract, but HealthEdge still needs to improve their relationships with clients. Quite frankly, HealthEdge is a little overstretched. My opinion is that for plans with fewer than a million members, HealthEdge is still the absolute best claims platform on the market right now. The HealthEdge product is essentially on a Microsoft platform that would have a very difficult time scaling once we got to a million members.” —CIO, current HealthEdge customer

conduent logo

(HSP)

Cross-industry vendor Conduent bolstered their healthcare offering with the acquisition of Health Solutions Plus (HSP). Payers who consider Conduent mention a good product and the promised development of new web-based/cloud and service-delivery options. While HSP has historically been a satisfaction leader in this market, customer satisfaction has fallen in the past year, with respondents citing less attentive service. The vendor’s market share has grown slightly in the past few years and is currently estimated by KLAS to be small.

“Health Solutions Plus was recently acquired by Conduent. Health Solutions Plus has more features out of the box than other vendors, so there is some appeal there. The vendor has a great API ecosystem as well, and I feel good about that. The vendor is currently running a thick client, and that is not going to be acceptable. They mentioned that they are looking to bring up a web-based interface in the next couple of months. Conduent offers a technology platform and some services, and that is good.” —VP, considering Conduent

“There is a sense that Conduent has our back or that there is a partnership. In every place I thought they would burn me, they stepped up. For example, they had many interfaces to write. There were enough where Conduent could have shifted a large portion of the interface writing to me, but they said they would just do the work. I am used to nothing being free. So far, everything through the go-live has been part of the initial statement of work. There have been no projects or extra money applied to any kind of scope. Most people don’t stick the real cost to us until the last one-third of the project when they need some money because they have burned through all of their hours and resources. So that was what I was expecting.” —CIO, selected Conduent

epic logo

Epic’s Tapestry solution is used (and considered) only by provider-sponsored health plans (PSHPs) owned by current Epic customers. PSHPs who consider Epic see the existing Epic relationship and the native integration with clinical Epic systems as strong purchase considerations. However, sometimes the purchase decisions are driven by the cost-conscious health system, rather than the PSHP, leaving the payer feeling forced to use Epic. The customer experience with Tapestry has been gradually improving over the last few years, but satisfaction with the solution is still lower than satisfaction with most other Epic products—customers often have high expectations for Tapestry based on organizational experience with the rest of the Epic suite. Epic’s presence in the core administration platform market has grown in recent years and is currently estimated by KLAS as small (and limited to PSHPs).

“The system was a natural fit with what we are doing across the health system. It was a fit with other parts of the enterprise as well, so it was an enterprise decision. The system may not do everything we want it to, but it is going to come close.” —CMO, selected Epic

“Tapestry is not a priority for the vendor. When we are at user group meetings and the vendor is showing off all the fun, new things that are coming, those things never have anything to do with Tapestry. It feels very much like we are a side product. From that perspective, I don’t get the sense that the executives understand that we need the product to be the best one out there just like the clinical side does. I feel like that is not really what is happening.” —Director, current Epic customer

mphasis logo

Mphasis is a cross-industry vendor who acquired the Eldorado product. Eldorado users interviewed in the past have largely been organizations who perform payer functions but aren’t traditional health plans. Historically, these customers have shared uncertainty about their future plans with the vendor. The interviewed organizations who have recently considered Mphasis are more likely to be traditional payers looking for a new core administration solution; of these, all have chosen other vendors. Respondent feedback has focused on concerns about the company’s smaller size and older underlying technology. KLAS estimates that Mphasis’ current market share is small.

“We liked the system, but it started running slow during our demos. We asked some very pointed questions and realized that some of the ways it writes to its database are really ancient. When Eldorado rewrites the system, they are going to force a huge upgrade that will cost $1 million or something. A system has to have enough stability and enough transformational ability in its back-end application that we can apply a patch without a rewrite of the whole configuration.” —CIO, considered but did not select Mphasis (Eldorado)

ss&c health logo

(DST)

SS&C Health acquired DST Technologies in 2018, and since then, a notable number of customers have either sped up their plans to replace the solution or have already begun a replacement. Current clients see the product as stable and solid but also old and stagnant. This perception has been reinforced by the fact that there has been no major progress on new development, and respondents don’t feel they have a clear vision of the solution’s future; all this has led to a high degree of uncertainty among customers. SS&C Health does receive some consideration in purchase decisions, though most considerations are by current customers who are looking to replace the product but want to give SS&C a chance. Their KLAS-estimated market share is midsize and appears to be declining quickly.

“DST Health Solutions has actually been pretty good as a vendor. They have had their own internal struggles, and they know they need to improve. We just didn’t see them as a go-forward vendor. The product is antiquated, and we couldn’t work in a value-based world with DST Health Solutions. We brought them back to the table to consider them for a new system because of the current relationship, but we will be going with a different vendor.” —CMO, replacing SS&C Health

“SS&C Health’s system simply wasn’t meeting the long-term needs of our organization. It didn’t have the level of flexibility needed to entertain new payment models. We had limitations in terms of how to manage certain types of benefits structures. It really required a level of sophistication from a technical perspective to configure and set up. The system was challenging for us organizationally, and we wanted a platform that would take us into the future and address our pain points.” —VP, replacing SS&C Health

advantasure logo

Advantasure’s customer base and brand recognition are often associated with government programs and the Blue Cross Blue Shield market, although they have a mix of customers, including non-Blues organizations. Originally called ikaSystems, a name some customers still reference, the vendor has undergone several transitions and rebrands in the last three years. Some existing customers have started looking at other vendors because of unkept promises and support issues. The overall sentiment among current clients is hopeful but not confident. Advantasure has recently been selected by a few new customers, who expect the vendor’s experience with Medicare and other government programs will produce the results they want. Advantasure’s KLAS-estimated market share is small.

“We decided last year that we wanted to get into a Medicare Advantage Plan, and we knew that we needed a partner to help us do that. We just didn’t have time to build something in-house. So we went on a search, and Advantasure was one of three vendors that we were choosing from. We ultimately decided to go with Advantasure because we felt like they were a good fit for our culture. We had a kickoff recently to implement the system. Advantasure is very customer focused, and that is really important to us.” —Director, selected Advantasure

“The vendor’s technology is good, but they continue to miss a few things. One thing they lack is execution. We set forth with plans, and the rules, regulations, and memberships change. The vendor’s execution is just not good. Once they get things up and running, the system generally works well, and we don’t have many issues with it. The vendor also doesn’t really have a vision for their road map. We know what the product does today, but if we ask about where the product will be in a year, the vendor doesn’t know. We don’t know whether the vendor is going to align with our needs.” —CIO, replacing Advantasure

plexis logo

Despite not being considered in many new purchase decisions, PLEXIS Healthcare Systems was selected multiple times when they were considered. Their typical customers are small to midsize payers, as are validated new customers. Decision factors cited by those who select PLEXIS include the vendor’s configurability, their focus on government programs, and pricing perceived as very affordable. Unlike most other vendors, PLEXIS was considered alongside few other vendors. Their current KLAS-estimated market share is midsize, with slight growth over the past two years.

“We were introduced to PLEXIS a few years ago through another health system that we were familiar with. That health system was using one of PLEXIS’ earlier products to process claims. We process a significant volume of healthcare claims. None of PLEXIS’ competitors had prior experience with an organization like ours, so we thought PLEXIS was somewhat unique in that sense. I hate to say that PLEXIS was the only viable option, but in many ways, they were the only ones who could provide us with the unique things that we wanted. We really like the alert capability within the product. We have a lot of hope for PLEXIS’ web portal base. We have a lot of casual users, and the web portal really simplifies the process of looking up an adjudicated claim.” —Director, selected PLEXIS Healthcare Systems

“We found PLEXIS by doing a Google search. I looked up claims adjudication software and found PLEXIS. I don’t remember what other vendors we looked at; our search wasn’t exhaustive at all. . . . We started looking into their system and found that it was very easy to configure and customize. That was very important for us and the main reason that we decided to go forward with PLEXIS.” —CFO, selected PLEXIS Healthcare Systems

virence logo

Virence Health (formerly GE Healthcare, now part of athenahealth) is used primarily by managed care organizations (MCOs) and is not considered by standalone health plans. Current customers in the vendor’s very limited market footprint report they are generally satisfied but also see the product as dated and not a strong go-forward option; at least half of interviewed clients have plans to move away from Virence. Those staying with the vendor usually also have other Virence applications. Consideration of Virence among non-clients is low, and KLAS has validated no new wins recently. Their current market share is estimated as very small and has been declining over the last several years.

“We are going to replace the product when we go live with another product soon. We have had a hard time getting GE Healthcare resources when we need to do an upgrade or when we have an issue. We also don’t want to be with a vendor that has an unstable future. There is no concern on our team’s part about replacing the product. The people on the business side are worried that they aren’t going to keep all the business-process customizations that they have developed.” —Manager, replacing Virence Health

oracle logo

Oracle’s core administration platform offering is relatively new to the market. It is not considered at a high rate compared to other solutions, but payers who do consider it express strong interest in what they view as a well-built product. However, because the product does not have an established customer base, some potential clients are wary of the risk of being early adopters. Current consideration energy is low, but Oracle has the opportunity to increase mindshare and adoption by leveraging their other healthcare products and technology. Oracle’s current core administration platform market share is estimated to be very small.

“Oracle was going to give us a good deal, but we just couldn’t take the risk of being an early user. Oracle’s product is beautiful, but we were scared of the risk. If there were 50 customers, we would all be contributing money, so if there were some regulatory change, that cost would be shared across 50 customers. So if Oracle didn’t make enough sales, more of the development would be on our dime. The government changes rules all the time. If Oracle got behind by three months, our stick wouldn’t be big enough to make them move faster. But we aren’t afraid of the system’s functionality. The Oracle product is robust and thoughtfully built from the ground up by Oracle for Oracle. It integrates with Oracle’s financial product, so the two products share the same database. Building a report is just amazing because that single database shares member, corporate, and enterprise data in one repository.” —CIO, considered but did not select Oracle

ram technologies logo

Consideration energy for RAM Technologies is low, and too few customers have been interviewed for KLAS to share performance data on the vendor. RAM Technologies is perceived by payers as having a small client base. They also have a BPO/BPaaS offering for Medicare, though it was not mentioned by responding payers. KLAS estimates their current market share is small.

“RAM Technologies and most of the vendors in the marketplace had poor market penetration and weren’t large companies. The only exceptions were Cognizant, DST Health Solutions, and HealthEdge. Most of the other vendors’ products had only one or two product lines. I wanted a product that could handle Medicaid, commercial plans, large group plans, small group plans, and individual family plans.” —CIO, considered but did not select RAM Technologies

Other Vendors 

This research includes those vendors who were considered, selected, or replaced by interviewed payers in recent purchase decisions. KLAS has validated or is familiar with a few additional vendors with commercial offerings in this market, including Citra Health Solutions and Virtual Benefits Administrator (VBA).

author - Elizabeth Pew
Writer
Elizabeth Pew
author - Jess Wallace-Simpson
Designer
Jess Wallace-Simpson
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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. © 2022 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.