TriZetto Exec Lists Challenges That Present Healthcare Organizations With Opportunities for Broad Improvement

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TriZetto Exec Lists Challenges That Present Healthcare Organizations With Opportunities for Broad Improvement

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Recent legislative mandates, including healthcare reform, have presented healthcare payers and providers with difficult challenges, but these same mandates have given the industry new opportunities to , , according to Harish Mysoré, an executive with , who spoke at a recent (ACG) forum in Boulder, Colo.

“The No. 1 challenge is near-term with coding and coverage mandates,” Mysoré said, referring in particular to a federal requirement called ICD-10, which increases the specificity of the diagnostic coding used in medical claims. Although the transition to ICD-10 has caused healthcare organizations to invest in technology changes, the additional data provided by the new coding can help health plans, providers and employers improve programs in health and wellness as well as utilization, care and disease management, said Mysoré, TriZetto’s senior vice president for corporate development and strategic alliances.

“The No. 2 challenge is a higher bar for operating efficiency and productivity,” he said. Healthcare reform’s medical loss ratio requirements have set minimum standards for payer spending on medical care, while medical equipment, rent and staffing are considerable costs for providers. “As a healthcare IT company, we always preach, ‘Automate, automate, automate processes wherever possible to improve productivity.’ We are urging our clients to examine workforce strategies and pursue cost-effective solutions for business processes and applications management.”

The No. 3 challenge to healthcare organizations is the need to “bend the cost curve while improving the quality of care,” Mysoré said, noting that each year in the United States $600 billion to $850 billion is spent on care that does nothing to improve health. “Historically, payers have not been in the business of providing care. They have been in the business of trading volumes for discounts (with providers). Health plans must become (PHM) companies, while providers must shift from a primarily fee-for-service model to one based more on value.”

Healthcare reform and the emergence of healthcare exchanges present the No. 4 challenge to both payers and providers, said Mysoré. Some analysts estimate that, over the next five years, 70 million to 100 million Americans will become active consumers of health and ancillary services. To meet the challenges and opportunities presented by greater consumerism, health plans and providers will need to implement technologies that help them understand, engage, respond to and build loyalty with consumers.

For healthcare providers, a key challenge—and opportunity—involves practice management systems and electronic medical records. Although federal law is driving adoption of these technologies, “as a country we still lag far behind some of the other industrialized nations,” Mysoré said.

During the panel discussion, which was moderated by Greg Anderson, managing director of the healthcare industry practice of investment banking firm Green Manning & Bunch, Ltd., Mysoré also commented on important trends in PHM and data management and analytics. “PHM presents providers and payers with a unique opportunity to improve the cost and quality of healthcare delivery by delivering relevant information at the right time at the point of service. This can close gaps in care and improve the compliance and choices of patients,” said Mysoré. “Further, ‘big data’ and analytics hold tremendous potential to help healthcare organizations move from applications to knowledge to insights to actionable information that can positively affect clinical outcomes.”

At TriZetto, Mysoré is responsible for mergers and acquisitions, partnerships and joint ventures that support TriZetto’s vision to simplify healthcare for everyone by providing solutions that improve the efficiency and effectiveness of the business of healthcare. He spoke at a forum in October sponsored by the ACG Denver, a business association in the Rocky Mountain region that offers corporate executives access to expert people and resources that can help drive middle-market growth.

TriZetto provides world-class information technology and service solutions that help payers and providers work more efficiently and to deliver better health. TriZetto solutions touch over half the U.S. insured population and reach more than 180,000 care providers. TriZetto helps healthcare organizations ; ; and compete to win in an emerging retail market. Payer solutions include , , and portal platforms, as well as , and . Provider solutions include real-time eligibility assurance, claims editing, that help providers get paid quickly and accurately. For more information, visit .