Solving health plan challenges: Operational efficiency

Perspective: Connected care | Capability: Operations and technology services, | By: Carelon

Carelon Chief Growth Officer John Hastings discusses how health plans can improve operational efficiency to drive ROI and innovation.

John Hastings, Carelon’s chief growth officer, has spent more than 20 years working with leading health plans in the healthcare industry. One of the primary challenges plans are facing today, he said, is improving operational efficiency, especially given limited internal bandwidth and a constant demand for innovation from key stakeholders, such as employers and members.

John recently answered some of our questions about how health plans are working to improve operational efficiency, free up IT and other resources, and improve their bottom line — and how Carelon can help make that happen.


How topical is operational efficiency for health plans today?


Ensuring operational efficiency is a big focus for all health plans, regardless of their size. At the end of the day, they have many priorities and very complex systems to manage. When there’s limited internal bandwidth — an issue that all health plans face — it’s harder to prioritize innovation to stay progressive. Tackling the underlying infrastructure of their operational systems is key. It’s really the backbone to delivering very strong service.


What are the consequences of being inefficient?


When health plans have aging systems or underlying operations that aren't connected, it makes it harder to enable that whole-person view and provide seamless member and provider experiences. Simpler systems are more sustainable, and they do a better job of removing barriers to care and making the whole healthcare system more personalized, accessible, and affordable.

This healthcare system is complex: it's not standing still, and there's continual evolvement, so you've got to innovate to stay ahead. And the first thing that will hold you back is if your underlying operational systems are not efficient or connected.

Operational inefficiencies can also drive up costs. If you're operating on multiple systems or systems that aren't talking to each other, it's inefficient because it's duplicative work. Whether it's claim engines, where you're looking at different systems to pay the claim, to answering a member call, to connecting all your clinical systems — if those aren't all talking together in an efficient manner, you've got an inefficient, high-cost solution.


Does this challenge change depending on the type of health plan?


Efficiency benefits any kind of health plan. Regulated businesses want to be as efficient as possible to maximize their financial performance and stay within mandated loss ratios, allowing them to avoid returning excess margins and profits to the government. For smaller health plans, they don't have the economies of scales of some of the big health plans, so it is a challenge when it comes to technology infrastructure, operations, claim platforms, etc.

Carelon is uniquely positioned to address all of that. We’ve got an enormous IT infrastructure, where we have both digital capabilities and resources that are flexible to provide efficient solutions that drive a better bottom line for those companies.


Can you talk more about how Carelon helps plans become more efficient and streamlined?


Carelon was born out of a health plan so we really understand the complexities of the healthcare system and how plans can and should respond to those complexities.

We’re positioned extremely well with our technology and digital solutions, with 25,000-plus associates who really understand this space. Whether it's an underlying claim, customer service, clinical platforms, or advancing value-based care to connect a health plan more efficiently with the provider community, it’s all really at the core of what we're able to do for health plans.


Do you have any examples of where you’ve done this?


We worked with a very large health plan and helped them reduce the number of claims platforms they used from over a dozen down to one — and the results changed their business. It saved them a significant amount of money, which allowed them to compete better in the marketplace. They could then refocus their resources on innovation to improve the quality and affordability of care as well as their member and provider experiences.


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