The Road to Transformation

The Road to Transformation
Ensuring your data processes and rules will meet the business vision
data,
for today and tomorrow

September 8, 2011 © Blue Slate Solutions 2011

About Blue Slate Solutions

• Improve operations - optimize processes,
I ti ti i
connect disparate systems, introduce relevant
Rules
technologies, manage data
• Clients include 2 of the top 3 and 4 of the top
20 health payers including 9 BCBS plans
h lth i l di l Solutions
• More than 100 healthcare-specific projects Process Data
spanning more than 20 different healthcare
entities, mostly Blues or their subsidiaries
• Experience across the full spectrum of Project & Change
healthcare payer functions and departments Management

Shawn Firehock David Scholl
• 15 years BPM experience
• 20 years general
within healthcare payers,
management and business
insurance and financial
leadership at GE
services
• Certified Master Black Belt in
• Designed pre-
Six Sigma (process quality)
adjudication platform for a
Blue • PM/BA on 9 workflow
automation programs within
• Worked with several
healthcare payers
Blues on transformational
change

2
© Blue Slate Solutions 2011

Strategic Focus on Business Process Management

Process

BPM
Data Rules

Architecture

Smart Approach. Extraordinary Results.
3

Blue Slate BPM Solutions

Project
Portfolio BluePrint
Prioritization

Process Drive Change
Analysis ROI Management

System
Tool Selection
Integration

Smart Approach. Extraordinary Results.
4

Blue Slate in Healthcare Payers

Clients
4 of the top 20 US Healthcare Payers
2 of the top 3 national payers
9 Blue Cross Blue Shield plans
3 Medicare Administrative Contractors
1 Top 5 Third Party Administrator

Experience
100+ healthcare-specific projects
25+ different healthcare entities

5

Our client

40 year old US payer, 2500+ employees across multiple
locations serving several million subscribers

Will current architecture serve future business vision?

How can we surpass our competition?

6

Two tracks; one destination

Current State Applications

Grounding
G di Technologies
T h l i
Strategy Organization
Business Technology

7

Business Track


Business methodology

Discover and validate strategy

Ground leadership in possibility

Conduct cross-functional interviews

9

Maturity and relative IT spending

10

Organizational maturity model: transformational change
Level 1 Level 2 Level 3 Level 4 Level 5
Informal/Ad hoc Formal/Documented Integrated Strategic Optimized

Individual Success Enterprise Collaboration
People “Fire fighting is a way of Highly Agile
life.” Strategically focused
Uncoordinated Rewarded on Enterprise
relationships Success
In competition

Process and Ad Hoc Adaptive
Chaotic Opportunistic
Technology
Inconsistent Proactive
Agile

Communication Ad Hoc Preventive
Chaotic Highly Adaptive
No single source of truth
g Opportunistic
pp
Community based (All
stakeholders)

Measurement Ad Hoc Data is used to evaluate
Manual and select process
People based
People-based improvements

Budget Ad Hoc Opportunistic
Uncoordinated Strategically Focused
Hidden spend
Individual Project based
I di id l P j t b d

11

Resulting transformational maturity progression
Level 1 Level 2 Level 3 Level 4 Level 5
Informal/Ad hoc Formal/Documented Integrated Strategic Optimized
Individual Success Roles well understood Program level Collaborative Enterprise Collaboration
“Fire fighting is a way of Coordinated Relationships Coordination Aligned Highly Agile
life.” 2a Commonality driven2b
Performance Measured Data driven Strategically focused
People Uncoordinated Customer focused
g
Standardized training Thinkers vs Doers Rewarded on
relationships Rules assume low level Enterprise Success
In competition tasks
Ad Hoc Emerging Defined Aligned Adaptive
1
Chaotic Standardized Structured Disciplined Opportunistic
Process and
Inconsistent Isolated Measured Predictable Proactive
Technology
Repeatable 7 Competent 6 Quantitatively Agile
Measured
Ad Hoc Common language Common language Aligned across Preventive
Chaotic emerging 2a Standards Training and outside Highly Adaptive
No single source of truth Gaps understood and Tied to Performance Enterprise Opportunistic
Communication reconciled Systemic Quality Checks Community based (All
Quality checks
8
Shift burden to Supplier t k h ld )
stakeholders)

Ad Hoc Standardized 2a Proactive Qualitative Data is used to evaluate
Manual Repeatable Aligned assessment and select opportunities
Measurement and People-based Emerging proactively Automated
Control 5
Silo Emerging Automation Enterprise
Portfolio
Ad Hoc Emerging Spend Visibility Clear Spend Visibility Aligned Opportunistic
Uncoordinated Coordinated 2 Program Approach Predictable Strategically Focused
Hidden spend Emerging Control Controlled Agile
Budget
Individual Project based Coordinated Projects ROI visibility

12

Actionable

13

Deliverables

• Definition of future state
Architectural paradigm
System logical diagram
System physical diagrams

• Detailed roadmap to target architecture,
organization and/or process

• Set of Quick-Win and Transformation
project plans (ROI, Staffing, Timeline)

14

Technology Track


Technology methodology

Discover IT organization’s
alignment and skills

Examine technology
capacity and flexibility

Assess application
functionality and data

16

Architectural maturity model: transformational change

Standardized Business
Business Silos Optimized Core
Technology Modularity

Companywide Plug and play
Plug-and-play
Local IT Shared technical
IT Capability standardized business process
applications platforms
process or data modules

ROI of local Cost and quality
Business Speed to market,
business Reduced IT costs of business
Objectives strategic agility
initiatives operations

17

The business operates, but how?

Classic Optimized

Mostly human with some static Automated, flexible, DSL with
Rules systems human for exceptions

Manual, escalation by
Automated, SLAs, consistent, cross-
Workflow complaint, process knowledge
department
by
b experience within d
i i hi department

Electronic repository, single location
Paper-based, curriers, access
Documentation challenges (
g (timeliness, copies) )
for all documents, effective retention
and security

Ad-hoc, broadcast, many pull
Communication requests
Just-in-time, targeted

Stove-pipe (department,
purpose and technology), Shared services, integrated data,
Systems redundant functionality,
y systems of record
y
duplicated or inaccessible data

18

Systems and stovepipes

19

Target architecture
View
Presentation Tier Layout
Online Provider
WS Services iPhone Android Facebook Security

Application Tier
Request ID Notifiier
NRQT … Aggregation
Tracking MAD
Business Rules
SDO
Services / Business Tier Work Flow
canonical data models Transactions
Security
y

Security Logging Member Data Provider Data Claim Data Other
Service Service Service Service Service Services…

Integration Tier object domain
j
Data abstraction
DAO
O-R O-XML O-Unstructured O-API / WS O-Screen Scrape Transactions
Security
native/proprietary domain
Enterprise System Components
EIS Tier
Persistence
Host Systems Document Mgmt Transactions
System
Categorization
OLTP data
sources
Indexing
Workflow Engine Messaging Security
LDAP OLAP data
repositories sources Rules Engine ETL

20

Deliverables

• Definition of future state
Architectural paradigm
System logical diagram
System physical diagrams

• Detailed roadmap to target architecture,
organization and/or process

• Set of Quick-Win and Transformation
project plans (ROI, Staffing, Timeline)

21

Keys to Leading Transformational Change

Align
Architect
Measure
Iterate
Apply 80/20

Avoid the Big Bang
Measure/Validate

22

Kick-start techniques

Leadership

Qualifiers and competes

High-value
High value data

Key process standardization
y

Commodity technology

Meaningful POC opportunities

23

Questions?

24

Case Study


Medicare Administrative Contracting

26

Problem
At A Glance

Our Client, a Medicare
Administrative Contractor
(MAC) looking to maintain
Problem their existing contract and
grow.
• Client estimated they needed >30% reduction in
cost/claim while taking on 2X workload Solutions
• Cost Driven Program
Strategy
• Prioritized program
elements
• Detailed requirements
• Impactful solutions
• Client self-sufficiency

27

The ‘As-Is’ Process

Inbound / Mailroom

Appeals

Medical Review

Overpayments

Outbound Correspondence

Process QA

28 © Blue Slate Solutions 2011

Define the Strategy
At A Glance

their existing contract and

1 Define the Strategy grow.
Solutions
• Become paperless
• Optimize Key Business Processes Strategy
• Leverage legacy systems and technologies • Prioritized program
elements
• Joint ownership between IT and Business • Detailed requirements
• Change management workshops sponsored and • Impactful solutions
attended by Senior Leadership – ensured buy-in • Client self-sufficiency
from the onset

29

Prioritize the Program Elements
At A Glance

grow.
Solutions
2 Prioritize the Program Elements Strategy
• Used a Six Sigma approach (QFD) in planning elements
• Focus on Centralized processes and paper- • Detailed requirements
heavy processes • Impactful solutions
• Implemented Governance at all levels including
monthly Executive Steering committee meetings

30

Gather Detailed Requirements
At A Glance

grow.
Solutions
Strategy
elements
3 Gather Detailed Requirements • Detailed requirements
• Involved Technical team from the start
• Used ROI and Productivity metrics to drive the
To-Be solutions
• Detailed Use Cases / Business Rules

31

Built Impactful Solutions
At A Glance

grow.
Solutions
Strategy
elements
4 Built Impactful Solutions
p • Impactful solutions
• BPM/workflow to streamline high impact processes
• Leveraged legacy DBs and data warehouse.
• ECM implemented to directly launch new workflow
p y
• IVR feeds workflow - improved caller experience
• Data masking tool to allow developers/testers to
work with non-production data (security)
• Manager portal provide real time view of inventory

32

Contact Center Optimization

33

Enable Client self-sufficiency
At A Glance

5 Enable Client self-sufficiency (MAC) looking to maintain
• Continual mentoring and technical guidance to
grow.
Client IT team
Solutions
• Developed systematic Knowledge Transfer
sessions Strategy
• Client is now self sufficient • Prioritized program
elements

34

The Payoff
At A Glance

grow.
Solutions
Strategy
Client Successfully Awarded the Contract ! • Prioritized program
elements
• Measured cost reductions of 25% to 40% in • Detailed requirements
automated departments with seamless transition to
p • Impactful solutions
new level of workload (2X) • Client self-sufficiency
• Improved Caller (customer) experience
• Change Management mindset starting to take hold
throughout organization - Workforce less intimidated
by continuous market dynamics / changing
requirements

35

Measurable Results

• Reduction of Cost per Claim and PMPM Cost
• Increased throughput with minimal impact on
operational cost
• Leveraging existing technology investments
through multi-tiered architectures and web services
• New technologies increase competitive position by
getting closer to providers and members
• More secure systems and data improve compliance
and minimize corrective actions and fines

36

Winning strategies to transform challenges to results

• Engage leadership and cross-functional teams and
establish strong project governance models
• Identify and prioritize opportunities, and formalize
as projects
• Question the status quo – search out redundancies
and hidden factories
• Leveraging existing technology
• Use rules and workflow to automate
• Introduce relevant and appropriate new software
for maximum impact
p

37

What’s on your mind?

38

The Road to Transformation

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