Plans should take full advantage of technology, operations to manage exchange markets

As Affordable Care Act (ACA) exchange markets evolve, health plans managing these markets face certain realities: many exchanges have not functioned as anticipated, technology has not always panned out, pricing often has been driven by poor data and inadequate risk assessment, and the market has been in a state of flux. However, during the transition to a more stabilized, post-ACA world, plans that keep the end game in mind — efficient, compliant, high quality and price-competitive offerings — are more likely to be successful.

For this to occur, plans must extend their focus beyond member acquisition, retention and clinical management to understanding the new roles that operations, technology and administration will play in the new paradigm. Plans should concentrate on strategies to:

  • Develop “big data” analytics capabilities for risk-adjustment payment.
  • Focus on analytics as the framework for clinically evaluating members, collaborating with providers on cost of care and modeling the most efficient path to managing and documenting members.
  • Consider new approaches for modeling data.

New environment calls for new approaches

In light of the new ACA environment, plans are finding they do not have enough information on the types of members now joining them. But with technology and algorithms, plans can better understand the risks behind each member, in absence of insurance claims data. Technology solutions can capture data, and also enable actuarial items to address and understand the risk that payers are assuming.

Operations and technology are important levers

As plans continue transitioning to this post-ACA world, determining how they can minimize the impact on their exchange business will be key. Plans should look to ramping up the use of operations and technology while remaining focused on improving the overall member experience. The following factors should be considered:

  • Continued price dispersion
  • Different consumer types
  • Member movement
  • Legacy data issues and process workarounds

Operations and technology capabilities can also help plans better understand membership volume and risk profiles, devise premium stabilization programs and monitor regulatory compliance.

For an in-depth discussion on managing exchange markets — including a step-wise approach to moving forward — listen to our on-demand webinar, “Plans Should Take Full Advantage of Technology, Operations to Manage Exchange Markets.”

About the authors

Vinay Koneru, Technology Solutions, OGS, Optum

Vinay KoneruVinay Koneru has over 20 years of total experience with about 12 years of it in US spanning across Healthcare, Telecom, Education and Financial industries. Prior to Optum, Koneru was a modeler, designer, architect, project/program manager, leaders, liaison, strategist, and innovator.


John C. Lloyd, FSA, MAAA, Senior Vice President, Optum Payer Solutions

John LloydJohn Lloyd is a Senior Vice President in the Payer Solutions practice of Optum. He is located in the Atlanta, Georgia office. John has more than 25 years of experience in the group insurance industry, managing the financing and administration of health and life products.

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