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 1. Home
 2. HealthEdge Blog
 3. Three Things Every CIO Should Consider When Evaluating Care Management
    Solutions


THREE THINGS EVERY CIO SHOULD CONSIDER WHEN EVALUATING CARE MANAGEMENT SOLUTIONS

Published Date March 30, 2023 Author Jennie Giuliany


 * 
 * 
 * 
 * 

The pace of change in healthcare has accelerated at record speeds in recent
years. Many health plan CIOs are struggling to help their businesses adapt
quickly due to their dependencies on legacy care management systems that were
built on outdated technology platforms.

As a result, there is a growing level of frustration among business, clinical
and technical leaders alike, and therefore a growing number of payers looking to
upgrade their care management capabilities. To help CIOs better understand and
prioritize evaluation criteria, Gartner recently issued a report entitled,
“Market Guide for U.S. Healthcare Payer Care Management Workflow Applications.”

The report stresses the urgency by which health plan CIOs should consider new,
more modern solutions. In fact, the Market Guide states, “The care management
function is one of the few remaining levers available to a payer organization to
impact its most important KPIs (namely top-line revenue, medical costs, quality
measure improvement and operational efficiency).”

But with so many options and considerations to make, how should CIOs go about
evaluating care management software solutions? Below are three of the most
important criteria every CIO should consider.

Interoperability with Other Systems

As the role of the traditional care management function continues to expand,
care managers are being asked to support a wide variety of business and care
delivery models that depend on coordination with a non-traditional service
providers, such as home-based care, community services, and behavioral health
specialists.

To support this evolving role, technical leaders are being asked to implement a
wide variety of systems, which has led to complex infrastructures, massive data
silos, and frustrated care managers.

The importance of having a highly interoperable care management platform that
works seamlessly with virtually any third-party system cannot be understated.
Interoperable systems with advanced APIs that require minimal IT overhead is no
longer a nice-to-have – it is a must have. No single care management system can
address all of the unique needs and care management goals of each payer so CIOs
must place interoperability and the seamless exchange of data, whether it be
structured or unstructured, as a top criterion.

Regulatory Compliance

For health plans, keeping up with the rapidly changing regulatory environment is
one challenge, but making sure an organization’s care management platform and
workflows can also be adapted to keep up is a whole different ballgame.
Traditional systems often require significant IT involvement and complex
rewiring of workflows to prepare for and implement regulatory changes. Some
changes can take months and mountains of manual resources to implement in a
traditional care management system. And with the pace of change ever-increasing,
it’s often too late for system changes and payers end up building
manual-intensive workarounds that cost time and money.

This is especially true for health plans serving government populations, where
each state can have its own set of rules. And with the rapid growth in Medicare
Advantage plans, Managed Medicaid programs, and self-funded employer plans,
health plan CIOs must have a modern, agile care management system that
facilitates rapid change to meet regulatory requirements such as Medicare
Advantage plan proposed changes or Medicaid state plan amendments.

In addition to a highly flexible platform, CIOs should look for care management
vendors who have proven expertise in the government space. With seasoned experts
on hand to translate business and technical decisions into clinical workflows
that enable upholding compliance, payers can be confident in their ability to
meet regulatory guidelines and even turn regulatory efforts into competitive
advantages.

Health Equity & Social Determinants of Health (SDOH)

As the popularity of value-based pricing and risk-sharing arrangements reaches
new heights this year, care managers are being forced to take a more holistic
view of their members’ health, which includes social factors and community
services that can have a profound impact on a member’s ability to access care
and adhere to treatment plans.

Things like lack of transportation, limited access to healthy foods, and
financial insecurities must be considered when building successful care plans.
Community services and local groups must be incorporated into the care team, and
as a result, care management solutions must accommodate for these
non-traditional service providers and the SDOH data they can provide.

Connecting members with resources available in their community plays a critical
role in improving member outcomes and satisfaction levels while also reducing
care delivery costs – especially if the care management system can accommodate
the data and resources.

Making the Move to Modern Care Management

In the 2023 Gartner Market Guide, HealthEdge was recognized as a Representative
Vendor for GuidingCare in the care management solutions market.

Known for its robust API network, expansive ecosystem of pre-built integrations,
custom configurations, and advanced analytic capabilities, GuidingCare and its
team of regulatory and clinical experts check all of the main boxes industry
analysts recommend to payers looking to meet the demand for more comprehensive,
whole-person member care management of the future.

Learn more about GuidingCare on the HealthEdge website or email us at
info@healthedge.com.

 

Gartner, Market Guide for U.S. Healthcare Payer Care Management Workflow
Applications, Jeff Cribbs, Amanda Dall’Occhio, 3 January 2023.

GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its
affiliates in the U.S. and internationally and is used herein with permission.
All rights reserved.

Gartner does not endorse any vendor, product or service depicted in its research
publications, and does not advise technology users to select only those vendors
with the highest ratings or other designation. Gartner research publications
consist of the opinions of Gartner’s research organization and should not be
construed as statements of fact. Gartner disclaims all warranties, expressed or
implied, with respect to this research, including any warranties of
merchantability or fitness for a particular purpose.


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