KLAS: Health plans crave IT for new business efforts

Utilization and care management solutions have been around for decades, but today’s health plans are looking for newer breakthrough technology to help them negotiate today’s changing market.

The latest report from KLAS, an industry research and consultancy firm, entitled “Decision Insights: Payer Care Management,” says health plans crave innovations that include solutions to help them manage multiple business lines and adapt to changing requirements for value-based care.

For the survey, KLAS interviewed 40 payers about their purchasing decision process, including which vendors they considered, selected and decided to replace, with a focus on utilization, disease and case management; care coordination and member engagement. KLAS validated the purchase decisions of those surveyed during the past two years.

KLAS found an increased interest in new vendors, the report shows.


Functionality is the main thing payers look for in a care management solution, the study found. The most common functions payers are looking for are reporting, templates and stratification tools, followed by the flexibility to create user-defined tools and fields. “Vendors who provide robust reporting functionality and system personalization have more considerations than their competitors,” KLAS says.

KLAS discovered that some payers are willing to pass over a solution if it is missing an appeals and grievance functionality, and a few payers complained of some vendors that lacked utilization management functionality being absent or not robust enough.

Payers are likely to replace their current system if they are challenged by missing functionality or if they can’t integrate it with comprehensive care management, the study found. Poor customer service from the vendor or lack of innovation also led to dissatisfaction in about a quarter of those surveyed.

The health IT companies payers reviewed for this KLAS report included ZeOmega; Cognizant (Trizetto); Altruista Health; Casenet; HMS Essette; Medecision; MHK (formerly MedHOK); VirtualHealth; HealthEdge; and AssureCare. Vendors with a dedicated product in this space receiving fewer than three considerations from the payers surveyed, included DST Health Solutions, EXL and TCS Healthcare.

ZeOmega, Cognizant (Trizetto) and Altruista Health ranked among the top three most favorably chosen by those surveyed. However, others who didn’t rank as high were also noteworthy, according to KLAS. “Among vendors considered for new decisions, VirtualHealth stands out to healthcare organizations as being a newer company and for having a user-friendly product,” KLAS said. “AssureCare, which has been around longer, is seen among interested payers as having a robust, scalable product.”

Payers surveyed said they would like to see more of a focus on coordinated, member-centric care management. They want to proactively oversee populations and incentivize wellness. In addition, they are looking for ways that IT can assist with the payer- and provider-driven value-based care environment and the shared risk and ownership payers and providers face. They seek automated member communication, individualized member engagement. And when it comes to claims and clinical data, they need predictive analytics.

KLAS shares its information with a caveat: The report is based on opinions from those surveyed, “which should not be interpreted as actual facts.” The report should be used as “a catalyst for a more meaningful and effective investigation on your organization’s part and is not intended, nor should it be used, to replace your organization’s due diligence.”

Access the full report here.