This PBM Shows How a Central Platform Keeps Service Streamlined Amid Consolidation

The past few years have seen rampant consolidation across the healthcare sector, with major health plans buying up companies all along the value chain. Streamlined care pipelines yield cost efficiencies that get passed along to customers – both in the private health and workers’ comp spheres – and larger organizations are better positioned to bring their financial strength to bear on behalf of carriers and claimants.

But consolidation is not the same as unification. Mergers and acquisitions can over time generate incomplete data sets, a disjointed experience for stakeholders, and poorer overall service.

David Young
President and CEO of Optum Workers’ Compensation
and Auto No-fault

Tony Martin
Chief Revenue Officer, Optum Workers’ Compensation
and Auto No-fault

“There are a number of companies in this market that have gone through significant acquisitions that are still servicing clients on multiple platforms and utilizing different operating models,” said David Young, President, Optum Workers’ Compensation and Auto No-Fault.

“From the owner’s perspective, this creates confusion over where they aggregate their analytics and reporting. They end up having to pull data across multiple platforms to get a clear picture of their business, and that increases the likelihood of errors and missed opportunities,” added Tony Martin, Optum’s Chief Revenue Officer.

There are, of course, good reasons why a healthcare company would choose not to centralize their businesses onto a single platform – namely, time and expense. Optum’s experience has shown, however, why investing in a central platform is worth it.

“In 2019 we bit the bullet and decided that it was in the best interest of our customers to provide a singular platform where they could access our services,” Young said. “As a result, we’re in a position to innovate, grow, and provide better service going forward.”

A Process “Not for the Faint of Heart”
Understanding the scale of their migration to a single platform requires understanding the many pieces that make up Optum as an organization.

Though known primarily as a pharmacy benefit manager, the company also has arms dedicated to ancillary services, medical services, including bill review, and extending to claim resolution/settlement solutions. To support those four branches, the company has over the years acquired 16 different service providers – each with their own system and way of doing things.

Successfully streamlining these services would require more than quick “Band-Aid” solutions. Instead, the process would involve building an IT infrastructure and incorporating the best parts of each existing platform.

“Each of the underlying systems that we acquired had their own benefits. So at the beginning of this process we laid out what the best case scenario would look like. How can we pull these disparate systems together so that customers not only keep all the existing capabilities that they’re used to, but enjoy an enhanced experience,” Young said.

Customers themselves ended up being a key part of the process.

“You have to partner with your customer to make sure that all of the interconnectivity between those systems is seamless. We tried to make the burden on our customers as minimal as possible through that transitional phase, but in some cases they did need to test some functionalities and switch to new FTP sites,” Martin said. “It’s a significant undertaking not for the faint of heart.”

Over the last 18 to 24 months, Optum’s entire book of business was migrated over into platform unification. Throughout the migration, data security and privacy remained protected – something Martin and Young attribute to the resources of their parent company, UnitedHealth Group.

“UnitedHealth Group has a very strong IT group, so we’ve been able to leverage their expertise throughout this process. We also have a very experienced IT infrastructure housed inside of the business unit, comprising 150 dedicated individuals that work specifically on our line of business,” Young said.

These efforts resulted in a common platform and central access point to services across the four core business units. “The process ultimately made us more collaborative, and ready to handle new growth,” Martin said.

The Benefits of a Single Platform
The back-end overhaul has produced several key benefits for clients. First and foremost: a seamless and consistent digital experience throughout the lifecycle of a workers’ compensation claim.

“There’s a journey from the initial injury through treatment and ultimately to claim resolution. Each of the acquisitions we’ve made has added or strengthened an ability to provide service at every step of that journey,” Young said. “That comprehensive approach, which we call Total Care Management, is what differentiates us in the market, but that value isn’t fully recognized if clients feel there is a disconnect between various phases of a claim. A single platform bridges those disconnects and simplifies the journey from start to finish.”

The second benefit is improved clinical outcomes. Centralized data aggregation, analytics and reporting ensure that adjusters make informed decisions with complete, up-to-date information.

“We invested in an enterprise data warehouse where we store all of the information from our various products. In VitalPoint®, our adjuster-facing portal, the warehouse is integrated with digitalization tools that let you really dig into the data and look for anomalies,” Martin said.

Those tools include risk scoring applications that allow adjusters to prioritize high-risk claims. Going forward, risk scoring can be applied predictively by identifying common characteristics of high-risk claims early in the process and flagging them for attention before they become complex.

Over the long term, centralized data can support more effective clinical claim management, lower costs, and better outcomes for injured workers.

Positioned for Future Growth and Innovation
The long-term benefits aren’t limited to improved claim management, however. A significant advantage of a single platform is that it’s easier to innovate and expand. New solutions can be implemented much more quickly across the board, and new acquisitions rolled in seamlessly.

The ability to accommodate new capabilities and more customers is critical, since Optum has no plans to stop growing.

The recent addition of Equian, a payment integrity solutions provider, exemplifies that strategy. Equian brings a robust bill review process with a proprietary clinical coding logic overlay – a real differentiator in the workers’ comp industry.

“Most people think about Optum Workers’ Comp and Auto No-Fault as a PBM, and although the market knows our industry-leading presence in pharmacy benefit management, we’re very focused on growing our other three  service lines, and with a centralized platform, we are poised to succeed,” Martin said.

The safety and dependability of the system withstood its first major test in March, when the pandemic necessitated moving 1,400 individuals to secure work-from-home environments – something Optum achieved in just six days.

“I was nothing short of amazed by how quickly and seamlessly our team transitioned. As unfortunate as the circumstances are, they have underscored for me the value of our people – they are truly our greatest asset,” Martin said.

“It’s because of their dedication, combined with our investment in technology, that we have the stability, strength and agility to help our clients achieve the best possible outcomes for the claimants for the long haul.”

This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Optum Workers’ Compensation and Auto No-Fault. The editorial staff of Risk & Insurance had no role in its preparation.