Care Management, Customer Service Must Converge

By knowing patients better, healthcare organizations can make them healthier while also making them better customers.

Susan Taylor, VP and Business Unit Leader for Healthcare, Pegasystems

September 26, 2014

4 Min Read

Last Friday. I ordered pizza from my favorite little Italian restaurant, Luigi's. I opted for one of their infamous pepperoni with green peppers pies, and after I made my choice the cashier said, "Ms. Taylor, wouldn't you like an antipasto salad with that?" ...and what a coincidence, I did!

The story behind the story is I almost always order an antipasto when I order a pizza from Luigi's, and had simply forgotten to this time. Curious, I asked how she knew my preferences when I went to pick up the pizza. She said her order system showed the last few orders' details. Later, as I was enjoying my dinner, I realized this was a great example of how simple analytics can make a big difference in the customer experience, as well as with upselling and cross-selling.

This struck me because we have been having a lot of conversations lately with large healthcare organizations about the importance of the rise of consumerism, and how best to optimize the customer experience. There's significant opportunity to use the power of information and analytics to improve the engagement of members -- especially as the full implications of healthcare reform are revealed.

[Ready for big changes? Read Who Will Be The Netflix Of Healthcare?]

This concept of using information and technology in new ways to drive the "power to engage" is coming up more and more as healthcare organizations continue to explore the convergence of care management and customer service. They are realizing that care management programs combined with Customer Relationship Management (CRM) programs are being recognized as a transformational cornerstone for health plans.

Care management has gone through many changes over the years, but most people agree that care management typically comprises case (CM), disease (DM), utilization (UM), and wellness (population) management. Once upon a time, these areas were usually completely separate, "siloed" programs. In fact, disease management was often carved out and out-sourced to other companies. In recent years this thinking has shifted significantly. The benefits of integrating CM, DM, UM, and wellness programs have been recognized, and most healthcare organizations are now implementing unified platforms to enable this important integration.

The new target: creating innovative, member-centric, fully integrated programs that now enable care teams to efficiently share information to improve the collaboration of care among all the stakeholders in the care equation. These programs usually have similar components, including a unified platform; a vehicle to aggregate patient information; an analytics module to identify and stratify the population; outreach capabilities; assessment and care plan generation functionality; workflow and automation capabilities; authorization/prior-authorization functionality; correspondence generation; outcomes management; and comprehensive reporting. The results of the programs are showing not only improved quality of care and reduced cost, but also great improvements in customer service scores and member retention.

Now, it's really cool to see the "light bulb" turn on over people's heads when they start thinking about the implication of integrating care management systems with customer service platforms or CRM systems. The possibilities are endless when utilization and appropriate clinical information is presented in a thoughtful and concise way to customer service representatives. In the past, if a member called customer service, she would be given the same information and treated the same way whether she were a young athlete in amazing shape, or an over-stressed person with serious co-morbidities, who hasn't had a physical in years. By integrating care management systems with the CRM system, the plan could offer the athlete a free gym membership to drive loyalty. The other person could be flagged as a candidate for a disease management program, and the CSR could explain that she may be eligible for a reduced co-pay if she completes an assessment and enrolls in a program that could significantly improve her health. Cool, right?

Now consider how the new "consumer" (member) thinks and add in some important capabilities like multi-channel and mobility, and you've got the start of a program that can truly change the game.

It's exciting to see more and more healthcare organizations starting to explore the integration of care management and CRM -- and even strategic integrations among CM, CRM, and claims adjudication systems. We see this as a potential quantum leap forward in both improving operational efficiency and taking customer service to the next level. It's this type of performance-driven modernization that will ultimately position healthcare organizations to compete more effectively in the post-reform, consumer-driven economy!

But for too many healthcare organizations, this concept is still a long-term goal, not a proficiency. Until all organizations are fully consumer-centric and completely technology enabled, don't forgot to order your antipasto with your pizza.

The owners of electronic health records aren't necessarily the patients. How much control should they have? Get the new Who Owns Patient Data? issue of InformationWeek Healthcare today.

About the Author(s)

Susan Taylor

VP and Business Unit Leader for Healthcare, Pegasystems

Susan Taylor brings to Pega her 20 years of successful experience with payer and provider technology and operations, most recently from Oracle Corporation. Prior positions include Sr. Director of IT and Operations, responsible for Harvard Pilgrim's enterprise business architecture and transformation initiatives, and founding VP at Allmedia Solutions, a clinical documentation company serving sub-acute care providers. Prior to that, Susan was a member of the technical research staff at Bell Laboratories where she developed rules-engines for integrated circuit routing. Susan has an MS CS from Columbia University and was 2010 AHIP Fellow. She has served on the board of professional organizations, including the Business Architects Association.

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