Driving Performance Improvement in Healthcare

As one of the nation’s largest member-owned healthcare services, this company empowers members to deliver exceptional, cost-effective care at every turn. They’re backed by network-powered insights in the critical areas of clinical, operational and supply chain performance.

LEGACY SYSTEMS WEREN’T IN GOOD HEALTH

Since 2010, this large member-owned healthcare service has provided over $3 billion in savings to its provider network through contract price improvements, analytics, and advisory services. Despite this, their internal and external users experienced operations, data analysis, and business roadblocks with existing legacy systems.

Notably, there was a lack of integration within and between the company’s data systems, leading to inefficient, segmented, and uninformative user experiences.

Users were required to interact with multiple sign-in processes to manage, order, and coordinate the hospital purchases. Users leveraging the legacy system were required to jump through numerous hoops to receive rebates.

Further, the existence of poor data quality in the pricing system for the healthcare service’s employees led to processing inefficiencies. Without system maintenance, employees suffered from a very negative user experience.

They wanted a scalable cloud-based business solution to replace legacy applications in order to create a more automated, streamlined, and intuitive experience for members and employees.

Improving Business Processes with Pega and AWS

Using the cloud-based Pegasystems’ business process management and business rules engine, we automated and transformed a variety of systems including eligibility services management, commitment programs, and contract price activation. We combined the AWS based Pega’s out-of-the-box functionality with custom-developed features to tailor and design workflows to be as user friendly and personalized as possible. 

Rather than manually loading data to match updated provider or program information, we utilized key back-end integration points to create flows of data directly from the original source within the company’s network into the new Pega-powered system. Exposing the live data eliminated the legacy application bottlenecks, which had required them to shut down the system for two or more weeks to process and update data in between quarters. The new system intelligently determines which processes are running in which quarter, enabling the users to enter the system and make updates regardless of the program timeline. 

Provider members are now able to sign up for a program, select their suppliers, and enter their purchase commitment proposals within a single screen flow and then easily manage those requests through a streamlined validation process, whereas the previous process navigated between two completely separate applications. This reduces end-to-end processing time for the users while giving them a greatly enhanced user experience.

The cloud-based Pegasystems platform was implemented on the cloud with Amazon Web Services to increase its dependability and reduce costs.

The AWS based Pega solution created new functionality for the healthcare services company’s users, optimized internal operations, and increased member adoption and dollars saved for its provider network.

A Healthy Dose of Improvements

Project highlights include:

  • Streamlined user experiences with simplified workflows and automated processes
  • Increased member adoption with an intuitive, integrated sign-up process
  • Enhanced data integrity and yielded data monetization
  • Eliminated bottlenecks, increasing the number of fulfilled requests and contracts
  • Increased processing capabilities and cut processing time with automated workflows
  • Reduced manual data input, enhancing data quality and transparency
  • Improved reporting capabilities to allow members more visibility into supplier programs
  • Accelerated time to revenue for new services
  • Reduced total cost of ownership for software investment and maintenance
  • Increased platform dependability on the cloud with AWS