There's probably no more exciting (or challenging) role in insurance IT right now than health insurer CIO. Not only is technology the foundation of just about everything payers must do to comply with the Affordable Care Act (ACA), which takes full effect in 2014, but healthcare reform is driving a significant change in health insurers' business models -- also significantly enabled by technology.
So it's a good thing Capital BlueCross senior VP and CIO Mark Caron, CHCIO, FACHE, declares, "I really enjoy the challenge of change." Not only is health insurance changing, he notes, but technology is as well, which makes it imperative "to identify where those opportunities are for the best bang for the buck for us to bring to the marketplace." In other words, he adds, "We want to help drive the cost structure down in the industry and make people better, and give them the tools to enlighten themselves to help them live better."
The scope of Caron's responsibilities illustrates what this involves. In addition to IT, Caron oversees the company's healthcare payer initiatives group, which creates accountable care arrangements and works with new reimbursement initiatives and Center for Medicare & Medicaid Services pilots. He also runs the corporate analytics group that is producing healthcare and financial analytics for Capital BlueCross.
At the same time, Caron is working on "driving our cost structure down, doing things smarter, better and more innovatively in IT, and partnering with the right partners." Add to that implementation of an enterprise architecture model, started in 2012, that "is about the business model and care models we as an organization have embraced."
It's all geared toward supporting a business strategy that prioritizes "creating medical value for our customers, and driving toward consumerism" -- the shift, which the ACA will accelerate, from a focus on employers to individuals as the primary buyers of health insurance, says Caron. "The role of technology is to drive innovative ways to meet those needs [and] market demands. We are going where our customers are, reaching out to them, wherever they are."
Consumerism "is not just insurance," Caron notes. "There are other services we are developing to offer clients," such as information about managing chronic illnesses. And as physicians and other providers seek help in managing new requirements and financial models, Capital BlueCross is focusing on "what kinds of information and tools will help them drive more quality measures and be more cost effective with care."
The concept of medical value, Caron says, comprises cost, access, selection, transparency and quality. "It's having a product that will allow you, at a certain price point that is affordable, [to obtain] the best value care at the best cost and the best quality" -- tools that help consumers understand why surgeons who perform the same procedure at different facilities charge different fees, for example.
None of this can be accomplished without data, and expanding Capital BlueCross' capabilities around analytics is a top priority for Caron. "We are building a platform that becomes much more extensible, and takes in additional data beyond traditional claims data," he says. "We're working with our physician partners, taking the clinical data out of the electronic medical records and continuum of care documents. We're using that data to start to better understand the risk factors about a patient."
New Era Of Collaboration
This kind of information sharing is part of what Caron sees as a new era of collaboration between payers and providers. "I believe now the industry is less us versus them, and more 'what we need to do together to drive costs curves down.' All the physician group and hospital group CEOs I meet with are much more open to collaboration," he says.
The insurer now can contact its customers with information about relevant special programs or offers. "We're going to send you a message however you want it, whether you want it as text, a pop-up on your iPhone or an email," Caron says. "The vision would be, at some point, an a la carte ability to pick benefits that you want at a price point and maybe network of physicians you want."
When such capabilities become ready for prime time, Caron says, they "will all be driven by a heavily analytical process that becomes foundational to everything we do. Our company is making substantial, multimillion-dollar investments in these tools and in extending the platform, so it truly becomes a population health management tool and a platform for our physicians and our clinicians. And we also are expanding it to be a market-driven consumer-focused analytical platform."
To develop these capabilities, Capital BlueCross has turned to IBM and its Netezza data warehouse offerings, SAP/Business Objects' tools and Optum's OptumInsight (formerly Ingenix) products. Still, Caron says, there are gaps in the health insurance technology market. "A challenge as the industry is evolving is that there is not one 'nirvanic' platform" that can handle all the different types of information required by the ACA, he contends. For now, the solution is "building an integrated platform by partnering with various vendors."
Another data-related challenge is the competition for analytics talent. This is especially tough in health insurance, where so much of the data management involves complex healthcare claims-specific codes and transactions. "There is a big shortage of people who are informatics savvy with healthcare," Caron notes. One step he has taken to address this problem is a partnership with Harrisburg University to create a fellowship intern program focused on healthcare analytics. The university offers a medical analytics informatics master's program, "and we are integrating with that, to evolve that program to become very focused on real-world experience, so students are not just learning in the classroom what the data and data sets are," Caron explains. "We are bringing them onto various project teams and working with them, having them use their skills to understand what the real world is around [healthcare informatics]."