ikaSystems' enterprise-wide systems help lower administrative costs for health plan members

The United States moved a step closer to major healthcare reform this weekend as the House of Representatives voted 220 to 215 to approve a plan that will, among other goals, extend coverage to an estimated 36 million people without insurance, create a government health insurance option and prohibit such contentious insurance company practices as denying coverage for those with pre-existing conditions and rescinding coverage without clear and convincing evidence of fraud. The nation’s health plans — particularly those with targeted offerings for the individual insurance market — should see in this an incredible opportunity to gain market share, according to Ravi Ika, chief executive officer of ikaSystems.

“In a year marked by raucous debate over the U.S. government’s appropriate role in healthcare, signs of consensus are finally starting to emerge with this bill, which will now move to the Senate for the final stage of battle,” said Ika. “Innovative insurance companies have not stood idly by during the debate but instead have turned to ikaSystems in growing numbers to help them prepare for momentous change. These innovators understand that the time is now to rethink their technology and medical management strategies, because only agile, enterprise-wide systems such as ikaEnterprise can help them contain medical costs by doing what is truly best for health plan members.”

As Ika explained, “ikaEnterprise is a single Web-based technology platform that can be used to increase automation and intelligence management across every health plan line of business: government and commercial, individual and employer sponsored. What does that really mean? First, we can help significantly lower administrative costs through more efficient data sharing and distributed transaction workflows. However, over 80 percent of the premium goes toward medical expenses.”

The decision about how those dollars are allocated rests largely in the hands of primary care physicians, who are billing for services, referring to specialists, ordering lab tests, prescribing pharmaceuticals and so on. The primary care physician, therefore, serves as an important gatekeeper of care usage, according to Ika: “Systems such as ikaEnterprise provide actionable, real-time intelligence to physicians about how their practice patterns affect both the cost and quality of care. Programs such as pay-for-performance, risk contracting, tiered networks based on cost and quality, and hospital contracts that use both cost and quality information are all important techniques to address the estimated 30 percent of medical expenses that are avoidable. All can be automated through ikaEnterprise.”

As health plans are aware, perhaps the most significant opportunity lies with managing member risk. The goal has been to seamlessly share the same processes and information between health plan administrative and care management staff, healthcare providers, plan members, employers and, as necessary, state and federal governments — all while reducing every process to the fewest possible human “touches.”

“This goal was impossible to achieve before technologies such as ikaEnterprise emerged, yet it is precisely what is needed to ensure that the healthcare needs of every American are clearly, quickly and efficiently understood and addressed in a way that makes sense for the healthcare ecosystem as a whole,” said Ika.

The key for health plans is to intelligently draw forth the health conditions of prospective members during the sales process and identify existing risk, then proactively measure Healthcare Effectiveness Data and Information Set (HEDIS) and other quality metrics to proactively determine changes to a member’s health risk over time. The amount and type of care management support that will optimize outcomes can vary widely, which is why ikaEnterprise was designed to keep a constant, electronic finger on the pulse of each member, detecting subtle shifts that might require a member to transfer seamlessly from system or wellness management to disease management to case management and back again, Ika explained.

Even when a high-touch intervention is required, the system is a constant presence, encouraging communication among the care team, alerting members to required tests, forwarding relevant educational information, and supporting physicians and care managers through nonintrusive reminders.

“Better healthcare at a lower cost — ultimately, this is what healthcare reform is striving to achieve. ikaSystems was founded on the belief that controlling healthcare costs is about intelligent, efficient and collaborative health management. With ikaEnterprise, health plans have the power to be major players in healthcare’s transformation and maintain their profitability,” concluded Ika.