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The health insurance industry today faces rising treatment costs, increasing consumer demands, and a highly competitive marketplace. Further, new regulatory and compliance requirements stemming from the Affordable Care Act (ACA) create a need for flexible IT strategies that keep pace with the transforming industry. As a result, healthcare payers are rolling out new customer-focused IT infrastructures. A smooth, streamlined IT transformation– one that drives efficiencies while maintaining quality for patients–is often the desired goal of today’s healthcare CIOs.
To meet these emerging challenges, Harvard Pilgrim, a not-for-profit health plan serving more than 1 million members in the New England region, set out on an IT journey–beginning in 2007 and nearly complete–to help achieve its core mission of providing the best service possible to its members and to support its innovative product and provider strategy.
The company set a primary goal for its “IT Strategy”–to replace its core operating system with a component enabled service-oriented architecture (SOA) solution. Stemming from the primary goal was a number of supplementary goals, including the following:
• Deliver capabilities back to the business sooner than with a big box implementation
• Enable the company to continuously prosper and grow while implementing the new solutions, preventing any blackout periods
• Implement modern, flexible architecture that continues to grow with the company
Set in motion in 2007, the IT Strategy took one year of planning and seven years of execution.
"Healthcare payers are rolling out new customer-focused IT infrastructures to meet growing operational and compliance needs"
Planning in Action
At the start of the project, Harvard Pilgrim needed to move 850,000 members from one IT environment to another without disrupting daily operations. To accomplish this, the company evaluated and mapped out the requirements to migrate each piece of the business (i.e., self-insured accounts had different requirements based on their billing and banking requirements). Next, they built and configured the network data management application–rolling out different networks at different times. The physical migration began in October 2011 and ended in September 2014.
Throughout the implementation process, the company incorporated a number of new solutions to its IT Strategy, including the following:
• Relationship Management System
• Enrollment solution
• Claims pricing engine
• Benefit solution
• Revenue management and billing solution
• Capitation engine
• Network data management
By late 2014, the company decided to separate the newly implemented benefits and claims adjudication system from its pricing system. Harvard Pilgrim tricked its legacy mainframe system into acting as a pricing engine, reducing potential risk by maintaining the old pricing engine and migrating in the new benefits and claims systems.
Reflecting on the Process
Looking back, Harvard Pilgrim’s greatest challenge was in finding a stand-alone pricing engine. It solved this challenge through the implementation of Oracle Health Insurance. The company remained an active player throughout the implementation, contributing ideas for the pricing engine and teaming up with the solution provider to achieve shared goals.
Challenging this process was the deployment of the ACA, which signaled constantly changing business requirements. The company operates across Connecticut, Maine, Massachusetts, and New Hampshire– each of which selected either a state- or federal-based exchange–which in turn created quite an “upkeep” challenge when in the middle of an IT overhaul as each state must comply with different requirements. While challenging, the company overcame this obstacle, and met its IT Strategy goals.
Today, with its IT strategy a realization, Harvard Pilgrim can keep health insurance as affordable as possible, reduce expenses, drive down operating costs, and process millions of transactions each year consistently and accurately–all while it continues to provide the best service possible to its members. But, the company’s devotion to efficient processes and customer services means its work is never completely done.