According to recent industry reports, five factors exacerbating cost, quality and access pressures are globalization, consumerism, aging and overweight populations, diseases that are more expensive to treat, and new medical technologies and treatments. The same report suggests a healthcare transformation strategy comprising of – transforming value, transforming consumer responsibility and transforming care delivery – as prescription for healthcare systems to remain competitive.

Today’s Health Plans operate under a wholesale business model in which the employer chooses what to spend, where to spend it, what the network is, and who the providers are. Health plan products traditionally consist of a financing vehicle and a provider network. In order to adopt a transformation strategy, Health Plans are looking to change their business model to accommodate how healthcare is purchased, consumed and delivered under the new market environment. It is widely accepted that with increased consumerism, Health plans need to adopt a retail product and services business model with possible inclusion of universal healthcare at either state or federal levels. Consumers will demand more and better care for every $ spent. Members will expect their health plan to offer quasi-customized products that offer customizable options within a customer service, medical management and a provider network.

Some of the business model drivers that would need enhancements to core claims processing systems and surrounding case management, financial and operational systems include (to name a few):

Multiple evolving plan designs for Consumer Directed Health Plans Need for enhanced Consumer Analytics and hence enhanced Actuarial Analytics Offer Full-service Disease Management Programs including medical advice Integration of Electronic Medical Records Incorporation of Medicare Advantage and Medicare Part D requirements Pay-for-Performance programs Enhanced Quality Transparency Complex Provider Contract Management & Case Management Automated PPO Claims Re-pricing Integrated Health and Wealth Management - Enhancement of product portfolio including assimilating hitherto separate pure play financial services and insurance offerings

Health plan product modularity will have a dramatic impact on claims adjudication and customer service because it will create a more complex infrastructure for accessing and assembling data to meet consumer requests. Therefore, plans will need to provide more information and decision-making tools, as well as multiple, self-service, and assisted contact channels (such as Web, e-mail, IVR, and other media) to help consumers select and manage their product and payment options. Current health plan IT and customer service systems are not equipped to handle this transformation to a retail business model. Most organizations' legacy systems are so old, outdated (20 – 25 years old) and monolithic that they will have difficulty handling new, more sophisticated functionality.

In the future, products will drive health plans' operational capabilities of sales and distribution channels, pricing and risk management, customer care, care decision support, medical and network management, claims processing, and membership accounting - rather than operational capabilities driving products. Yet, moving from today's reactive, manually intensive business model to a proactive, information-driven one will require technical capabilities that are significantly evolved.

PluralSoft combines years of Information Management experience along with health plan domain expertise and our Clinicio™ framework to deliver solutions to payer organizations by leveraging our proprietary solution frameworks and our technology partnerships. PluralSoft helps payer organizations traverse the existing landscape of packaged point applications and service-oriented architectures to enable administrative consistency, accuracy, and efficiency across

	Front Office (such as Sales & Marketing, Member Portals, Provider Portals, Customer Service, Channel Integration, EDI/B2B Services, Consumer Analytics),
	Core Operations (such as Membership and Enrollment, Case Management, Electronic Document Management, Contract Management, Claims Processing, Adjudication, Commissions, Revenue Management, Decision Support – BI and Analytics, etc), and
	Process Automation and Integration tiers of required enterprise service-oriented information technology infrastructure (such as middleware for service creation-provision-consumption-orchestration-governance, business rules engines, workflow and intelligent routing, security, etc)