Business Process Management at the AHIP National Conferences on Medicare & Medicaid

The AHIP National Conference on Medicare & Medicaid just took place in Washington, DC. You can think of this as the public program version of the AHIP Institute conference I attended in Nashville during June. That conference focused on commercial health insurance payers and health plans. This conference focused on multi-billion dollar federally-funded health plans covering many tens of millions of Americans.

As usual, my workflow radar was on and antenna up, looking for interesting healthcare workflows and workflow technology content. I visited every website of every exhibitor to see what their “workflow stories” were, and then tweeted about it during the conference on the #McareConf and #McaidConf hashtags. I created a Twitter list of AHIP/CMS exhibitors, if you are interested in following them.

In this post I’d like to highlight perhaps the most sophisticated use of Business Process Management (what workflow tech is called these days) that I have seen in the health plan insurance payer space.


Joe Miller, Director of Strategy and Innovation, AmeriHealth Caritas, laid out challenges and opportunities for improving the health of its 6.9 million members across 16 states plus Washington, DC. Prominent in their solution is Business Process Management (BPM).


I was initially alerted this would be an exceptionally interesting presentation when I say these labeled icons in the upper right: ALERT/WORKFLOW, PROCESS/ACTION.


Before we drill down into the BPM solution, let’s review the problem commercial and public health plans need to solve. Customers, including Medicare and Medicaid customers demand more collaboration among everyone involved in their care. The more payment rewards value, the more it rewards collaboration, necessary to create value for patients. Cost pressure requires elimination of redundancy, rework, and mistakes, all of which require more collaboration.

Part of the problem is the potential for missed opportunities. These include widespread electronic health records, availability of their and other data, and health information exchanges to move that data where it is needed.

However! Along with these pressures and opportunities comes risk! Risk includes real and perceived threats of breaches of patient data, increased amounts of bad data, and changing consumer preferences (what do health plan customers “really” want?).


Magnifying and complicating the above drivers, opportunities, and risks, are a plethora of new data sharing opportunities, patient engagement channels, and complicated relationships with care givers and care support organizations.


Then there it is! Prominent in the technology mix necessary to solve these problems and grasp these opportunities, AmeriHealth Caritas is using Business Process Management (the Appian BPM app platform). I think it’s worth transcribing this entire slide and considering each bullet in turn.

  • Institute integrated business process management (that is, “integrate” into existing, evolving infrastructure, such as master data management and enterprise service bus)
  • Detail cross-functional workflows for defined stages of provider enrollment and maintenance (that is, integrate workflows across the functional silos present in most healthcare organizations)
  • Create role-specific user interfaces (UIs) for desktop and mobile (show all and only the necessary data, at each workflow step, to every user, which dramatically reduces time to learn and increases productivity)
  • Stream role-pertinent news, trigger tasks, provide pinpoint data access, and produce status reports on work in progress (generally, keep everyone up-to-data about peripheral but potentially relevant information, automatically begin workflows, and provide transparent views of all workflow task status from the beginning to the end of critical workflows, so no task languishes and everyone is on the same page)


Above is an impressive list of BPM benefits: improved management of provider networks, more accurate data, more timely processing, greater efficiency due to automated task assignment, calendaring, task tracking, and cross-functional (cross-departmental) hand-offs. Plus the ability to more quickly role out new products and services. Finally, improved provider information ensures more effective medical spending and more informed members making better decisions.


Before I end this post, I want to circle back to several very interesting slides. First, there is this “Keys to Successful Data Sharing — Workflow and Analytics”. I’d like to call your attention to alert and event types, plus risk level and category. By combining ATD (Admission-Transfer-Discharge) information from the health information exchange with clinical information about the patient, health plans can trigger carefully designed workflows — in real-time — that is, soon enough to actually have an impact of the health outcomes of the patients involved.

[The following paragraph is me editorializing...]

This kind of real-time process-oriented (what academics call “process-aware”) coordinated collaborative health plan activity is simply not possible without the kind of functionality and flexibility provided by modern business process management.


Finally, here is a classic box-and-arrow “marketecture” diagram for a planned consent management solution. It was explained that as data and workflow fall into place, it is realized that the health plan needs a sophisticated and comprehensive means to make sure all data, pushed through all workflows to patients and providers, complies with all necessary regulations … in real-time. While not specifically labeled “BPM”, this is the technology that will implement the necessary internal and external workflows depicted on the left side of the diagram.

The AHIP National Conference on Medicare & Medicaid in Washington was by all accounts a fantastic conference. I especially enjoyed hearing about the Celebrating 50 Years of Public Programs session from @cFisherAppian (The Path to an Easy, Powerful, and Unified Health Plan System).

To get to an easy, powerful, and unified health system, we need easy, powerful, and unified technology.

Clearly AmeriHealth Caritas is well on its way to its own version of this easy, powerful, and unified health plan information and workflow infrastructure. And they are doing so with the most sophisticated application of Business Process Management I’ve yet seen in the health plan space, commercial or public.

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