BPM & Healthcare Q&A with Scott Polansky, Appian Practice Lead for Healthcare Payers

Welcome to one heck of a freewheeling discussion with Scott Polansky, of Appian (Booth 238 at AHIP Institute), about the wide variety of ways to use BPM software to obtain 360-degree comprehensive and integrated views of member patient data, and then do really cool things in real-time contributing to member experience. What stood out to me, after rereading the transcript, is the intriguing fit between Scott’s experience designing management health plan products and his job, since Appian BPM can be used to so quickly create and deploy mobile software necessary to support new health plan products.

BPM stands for Business Process Management. It is rapidly diffusing into health insurance IT infrastructure. I’ve long been a fan and proponent for more use of workflow technology, AKA BPM, in healthcare, so I am delighted to have this conversation with Scott Polansky, Appian Practice Lead for Healthcare Payers.

CW: Scott, tell us about yourself!

Ha! Where do you want to start? I started in this business back when HSA stood for Health Systems Agency, not Health Savings Account.

CW: That was late 70s under Nixon, right? My graduate advisor headed the Health Systems Agency in central Illinois.

Right. I started as a premed major and then got a Masters of Public Health from UCLA. I did product development for health plans, leveraging my quantitative background and what is now called predictive analytics. I sold cost accounting software. Consulted for some boutique consulting firms helping providers get into the health insurance business. I came to Appian because I realized health plans must become more efficient and effective and Appian provides that kind of smart work platform.

CW: I want to drill down on Appian’s special work and workflow secret sauce in a moment. But first, I’d like to follow up on our conversation at Appian World.

CW: You emphasize something you call “relentless incrementalism.” What’s that?

Relentless incrementalism is all about taking a series of small steps toward a goal and being persistent. Even daunting tasks, from eating an elephant (a bite at a time, not that I recommend doing so, I love elephants) to cooking a frog (while doing so, up the temperature a degree at a time, and I like frogs too!) can be accomplished through small but persistent steps. Think of Agile Development, which in my mind is a form of relentless incrementalism.

CW: “Relentless incrementalism.” I like that. How does it relate to health plans and the software they use to achieve their goals?

Good question! Consider different, ultimately flawed approaches, to transforming health plans with information technology. On one hand there are those who are accused of automating “cow paths.” What’s the point if you going to accomplish the same bad workflow faster and more consistently? On the other hand some recommend “big bang” re-engineering: fix all the workflows at once, because you won’t get another opportunity after you’ve automated them. Appian BPM is third way to use IT to transform health data and process management.

CW: Huh! Now you’ve got my attention (though I must admit I do suspect where you are going with this…).

The key to transforming health plan data and process management is through relentlessly changing and improving data and process management strategies, all the way from, perhaps, cow paths, to eight lane super highways, one bite, one degree, one lane at a time. Entire sophisticated health plan software applications can be built in just week, sometimes days. And then, even after they have been deployed, you can gather data (the software gathers it for you) and then use that data to change the software (both data views and process activities) gradually and systematically until you get your desired intended level of efficiency and effectiveness. Figuratively, Appian BPM allows you to automate and then still change, subject to human users’ tolerance for change, until you eat the entire elephant.

CW: I love it! BPM software, and Appian is consistently top ranked in that category by Forrester and Gartner, is so cool.

CW: OK, let’s talk about another couple areas near and dear to my heart. First, let me note, some parallels between your background and my background. I was a premed accounting major. I took a wide variety of operations research and management science courses. I ended up incredibly excited by Business Process Management in healthcare. You were premed. You’re foray into actuarial science and predictive analytics reminds me of some of the topics in those courses. And here we both are, just before the 2016 AHIP Institute and Expo, enthusiastic about what Business Process Management can do for health plans.

CW: So, here’s a question for you. I think it may have been Einstein who said if you can’t explain something simply, you don’t understand it. What is actuarial science and why do we need it?

I am not an actuary. I don’t have that degree or initials after my name. But I am a recovering underwriter.

Actuarial science is using historical data and trends to predict future costs or incidents. Why do we need it? When you are building new products or managing existing products, actuary science allows you to look at historical costs and utilization, and when you put those together you can calculate an overall premium. Note well, actuarial science tells you what the rates should be based on historical data but actuarial science does not necessarily look at market or competitive forces. (BTW, actuaries don’t always appreciate this comment…). Basically, premium pricing is an art form and actuarial is a key input. Folks sometimes joke that actuaries drive down the highway looking in rearview mirror. To drive we need to look both backward and forward. What we seen in the mirror can predict a lot. But sometimes we need to incorporate other information.

CW: You mentioned cost. Do healthcare organizations and health plans know their true costs?

I can definitely say, as someone who used to sell cost accounting software to hospitals and health plans, that the answer is typically no. Hospitals have a much greater sense of their cost and do use sophisticated cost accounting systems, whereas most health plans do not. They typically measure medical loss ratio as an approximation. Ultimately, both health plans and their healthcare organization partners need a better and more comprehensive view into the costs associated with a patient member episode. In fact, I suspect that part of the reason we see such remarkable disparities in pricing, say $4K for vaginal delivery at a good community hospital versus $13K at the downtown medical center, is lack of accurate internal cost information (along with the fact that the patient isn’t paying that difference, rather the insurer is).

In general, providers have better overall cost information that health plans. But even there when you are a member facing a specific diagnosis or procedure, that cost/price doesn’t always add up to the overall cost/price.

To health plans, they may know cost of product lines at the level of commercial vs Medicare. But when you start drilling down toward specific products and benefit packages within product lines, they start losing accuracy, since they don’t have a good way to allocate administrative costs. Also, many companies offer both PPO and HMO products and it is important to price the PPOs higher even though the experience at a specific employer might show the HMO to have a worse claims experience.

Admin costs are maybe 10% so they have pretty good idea of overall costs, but when margins are 1-2% this is still a problem.

CW: How can BPM software, such as Appian’s, help better manage costs?

Whether about costs or care management or market intelligence, most of the software at health plans tends to be fairly siloed. Even when users can get at all the information they need, they’re using swivel chair interoperability, they’re sitting there with three screens on their task and they are looking back and forth trying to connect them.

Plus, a lot of health plans have outsourced a lot care management components. One company is doing disease management and another company is doing DME (Durable Medical Equipment) and then you have the pharmacy benefit management…. the point is you have all these disparate systems. So health plans have a difficult time integrating all this data to obtain a single 360-degree view the member and/or patient. And! Even if they can get this information, the information is so old it is not actionable.

BPM can pull data from different systems and make that data actionable by allowing the user to drill down. Appian also incorporates powerful workflow management capabilities so that tasks can be assigned when data falls outside a prescribed expected value range . As a result providers interacting with health plan get a much better impression of care managers because the care management really do have a more comprehensive and integrated real-time actionable view of patient member data.

By eliminating manual spreadsheets, care management improves and cost overhead drops.

CW: How does Appian’s BPM software help accomplish this comprehensive, integrated, real-time, actionable view patient and member data?

We’re a platform. We don’t have pre-canned applications. We come in to our customers and help them with workflow management and business processes, by using our very flexible platform application to connect and automate data and workflow silos. This platform application is low-code/no-code to it is the actual users who create their applications. At the core of our platform is the concept of a “record” which can be defined by the user. Think of Products, Providers, Members, That is how flexible the Appian software is. Or course IT is still involved, because they provide access to data in existing systems.

We’re not trying to conquer world hunger. We aim for quick solutions and then build off of those. Back to our discussion about “relentless incrementalism”… We see a lot of competitors with large inflexible applications that can take years and millions of dollars to get to a solution. We’re able come in with quick fixes, sometimes in just weeks, that then flexibly scale. Their rebuilt applications can’t be customized anywhere near as much as Appian’s BPM software, in which entire workflows can be reworked without involving traditional programmers.

Another problem with traditional approaches is that companies buy and collect a bunch of company applications that don’t talk to each other easily. With Appian all of our workflow applications automatically already talks to each other because they are on the same workflow platform.

CW What are some other advantages of the Appian BPM platform?

Well, we are the leading provider of cloud-based platform as a service. We give our customers the options of hosting their own applications or host in the cloud. Second, when you deploy a workflow application in Appian, it is automatically available across a wide variety of platforms natively, desktop, iOS, Android, etc. Both of those advantage, cloud and native mobile, is totally where the world is moving. Everyone wants to manage everything from anywhere whenever they want.

CW: I’m reminded of a recent conversation with several consultants aiming to build a practice applying BPM in healthcare (and looking at Appian for the enabling tech). We noted that Appian’s draw-workflow-once, deploy native-everywhere and especially to mobile, would be fantastic for health plan member mobile self-service apps. Any thoughts on that?

Scott: For example, how about providing health plan members with real-time update about their physicians’ schedules? I thought about this the other day, when I was comparing real-time emergency room wait times on billboards as I drove past. Why can’t we do this for physician offices too? Think about the incredible loss of productivity in this world because people show up at the doctor’s office and have to wait for an hour and a half, when the physician knew they are running later. There are plenty of valid reasons for running late. Someone shows up for a routine physical and it turns out they have some significant symptoms that need to be dealt with. Imagine a native mobile BPM app receiving a notification the physician is running late. IT provides access to internal systems, such as scheduling, and mobile, cloud BPM provides the smart workflow and mobile experience necessary to improve health plan customer/user experience.

CW: I love your idea, especially since medical office scheduling systems both drive, and are driven by workflow design and real time workflow state. A schedule is a set of timed tasks kickoffs, with additional downstream tasks, because each schedule appointment is really a collection of tasks. For example, chronic asthma versus camp physical, and so on. If providers and health plans could make task and workflow state more transparent, in real-time, and then feed that out to the folks who need to know that real-time info, it could be a big win-win, for the health plan member and health plan provider.

CW: Let’s see, premed, cost accounting, actuarial science, product development, health insurance… I’m always fascinated by how folks reflect the evolution of an industry. I know we opened talking about how you got to Appian, but let’s drill down a bit more.

Scott: Well, after my MPH from UCLA I did marketing for an HMO, then finance, accounting, underwriting, sales, business development, product management, I really like to move around, learning new things all the time. I think my favorite area is product management, because it bring a lot of disciplines together when your building and launching and managing health plan products you really have to be aware of almost everything going on in the organization, to be able to price these products accurately, you need to be able to market and sell them appropriately, so you have to provide a lot of training and education to sales and customer service folks, and ultimately you need to make these new products as understandable as possible to health plan members.

You have to understand your customer. That’s one of things thats always driven my career, you always have to take the “outside it” route to product development. One of my favorite saying about health payers is we’re too busy looking in the mirror instead of outside the window.

CW: “Outside In.” I like that. It reminds me of I’ve heard of BPM applications as “outside in” systems. IT manages IT infrastructure (networks, hardware) and supplies access to data. Then BPM applications are crafted by, or at least with direct input from users, using low-code approaches, to build from the “outside” (closest to the customer) toward the “inside,” the traditional enterprise transactions systems.

CW: Your background in product management… it seems like a lot of the folks you are interacting with now are probably trying to figure out how to create new products and services for their members.

Scott: What drew me to Appian when I first heard of it is I do not have a software background. I am more of a business and applications guy. What really intrigued me about Appian was this opportunity and ability to start with a blank slate and to connect all of these data sources together and incorporate workflow management plus the sophisticated reporting. Ultimately, it all comes down to providing timely actionable information.

CW: That word “actionable”… how does Appian BPM make health plan data actionable?

Scott: In a couple of different ways. First the data is presented in an appealing and easy-to-use reporting output with a user interface in which you can easily drill down into any and all of the data. You start out at the top of the funnel and then in just a couple clicks you can get down the level of an individual claim. You can start out looking at a specific product line and then in a matter of minutes you can look an entire class of claims, such as how much are we spending on pharmacy for HMO products that have $5000 or more deductibles. That’s just a quick example.

Second, the data is timely and coming from multiple sources. Here is one example from my product background. One of the things we struggled with was that we’d launch a new product, and, unlike manufacturing, we have a large lag between claim information being meaningful and when we could act on that info. When someone has a claim it can be two to three months before it comes into system because maybe the provider sat on it, maybe the claim wasn’t clean, so it has to go back to the provider, the point is there is a significant built-in lag in trying to observe the performance of product form a claims standpoint.

For example, Appian could link drug data (which can impact product performance), for which there is less lag, to product performance. The point I’m making is that with Appian we have the opportunity to link customer service data and product data. In the past I did not have this linked data so I had no idea whether a product was getting an inordinate number of claims kicked back or a large volume of customer inquiries. If we are able link the systems together, I could have had early warning data, in the “canary-in-a-coal mine” sense, whether a health saving account product we launched was a disaster or not. If I had that call volume data upfront we could have made adjustments to the product in a matter of weeks instead of instead of waiting nine months to start seeing some of the financial data. We could have seen the problem sooner in the customer service data.

CW: You’re getting better data sooner and then you are more easily changing your workflows and processes via BPM’s low-code to improve the data.

Scott: Right, it’s Relentless Incrementalism. It comes back to that. We’re able to keep tweaking the products workflows without have to go back to the software vendor for customization. You have much more flexibility with Appian software. Here is a quote from our CEO Matt Calkins who said, “Software in the first 30 years was about efficiency. We see the next thirty years as using modern BPM software to empower.”

CW: Fantastic. I so agree. Well, Scott, I know you have to go soon, so just one more short question. I just want five words from you. You’ve been to AHIP, the America’s Health Insurance Plan conference many times before. Now you are with the Appian business process management company. In five words, what on people’s minds at this years AHIP Institute? What will be in the air, almost symbolizing a moment in time in the history and evolution of health insurance?

Scott: …… [long pause] Can I have seven words?

Chuck: Sure!

Scott:

  • Consumer Engagement
  • Interoperability
  • Actionable Reporting
  • Efficiency & Effectiveness

Chuck: OK! I suspect you have accurately captured this year’s Zeitgeist at the AHIP Institute and Expo. And I look forward to seeing you there! What’s Appian’s booth number?

Scott: Booth #238 in Las Vega, June 15 and 16 at AHIP. Thank you very much! I enjoyed this.

Chuck: Me too. See you there.


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