Decision CAMP 2014 - Carole-Ann Berlioz-Matignon - Preparing for exceptional behavior
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Healthcare plans are customized for each client. Insurance companies have to incorporate all changes negotiated for each customer into their automated system. Carole-Ann will present techniques that have been adopted by Healthcare Insurers to reduce the number of business rules into their systems, and therefore reduce the maintenance on their traditionally creeping systems.
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Decision CAMP 2014 - Carole-Ann Berlioz-Matignon - Preparing for exceptional behavior
- 1. Preparing for Exceptional Behavior Business Rules / Decision Management In Healthcare Carole-Ann Berlioz-Matignon cmatignon@sparklinglogic.com
- 2. Introductions Carole-Ann Berlioz-Matignon Co-founder & CPO Sparkling Logic @cmatignon
- 3. Case Study Division of BCBS of TN Delivers Wellness programs to BCBS of TN and others
- 4. Wellness Programs What are they? • Offered by Medical Insurance companies • Complement Insurance policy • Aim at keeping members healthy, preventing expensive disease down the road • By promoting / encouraging good behavior Why? • Healthcare cost skyrocketing • Few diseases cause major financial burden • Saves $$$ in claims • Evolution towards Population Health Management • Healthier employees are more productive too • And improves quality of life for member
- 5. How it works Detect At-Risk Population Educate / Encourage Good Behavior Reward based on Activity / Results
- 6. Lots of Decisions Detect At-Risk Population Educate / Encourage Good Behavior Reward based on Activity / Results Who is at risk? Which activity would prevent disease? Which incentive would they respond to? What reward should they be credited for? Did they fulfill all the requirements for the reward?
- 7. Onlife’s Challenge #1: Velocity Issue Detection Victim of our Success More Members Æ More Volume Plan gets updated with every activity reported, lab test received, etc. Wellness Recommendation Activity Monitoring Reward Accounting x15
- 8. Onlife’s Challenge #2: Diversity InsuraInncseu rAaInncseu rBaInncseu rCance D Issue Detection Victim of our Success More Customers Æ More Customization Each program has its own specificities Æ Different Rules Issue Detection Wellness InsurIannscuera Ence XYZ Issue Detection Wellness Issue Detection Wellness Recommendation Issue Detection Wellness Recommendation Issue Detection Wellness Recommendation Activity Monitoring Wellness Recommendation Activity Monitoring Recommendation Activity Monitoring Recommendation Activity Monitoring Reward Accounting Activity Monitoring Reward Accounting Activity Monitoring Reward Accounting Reward Accounting Reward Accounting Reward Accounting
- 9. Using Decision Management Issue Detection Wellness Recommendation Activity Monitoring Reward Accounting Data Data Data Data Data Data Data Data Data Data Data Data Data Data Data Data Data Data Data Data Data Data Data Data Data Decision Service
- 10. Cascading Business Rules Issue Detection Wellness Recommendation Activity Monitoring Reward Accounting Generic Rules Insurance A Decision Service With a twist Insurance B With less rules Insurance C With more rules
- 11. Key Benefit Issue Detection Wellness Recommendation Activity Monitoring Reward Accounting Decision Service Flexibility & Agility New rules can be managed by domain experts • Clinical team • Product team
- 12. Before… Product team Clinical team Spreadsheet Most of the time spent here… Would have been okay for short term Development Testing
- 13. Initial Focus… Solid Architecture Now… Product team Clinical team Decision Service Minimum time spent here… Initial Rules Repository with full Traceability, Lifecycle Management & Governance Deployment on the Cloud
- 14. After… Product team Clinical team Decision Service Most of the time spent here… Quick Enrollment Repository with full Traceability, Lifecycle Management & Governance Deployment on the Cloud
- 15. Skills Profile of our Rule Writer • Business Analyst • Technically savvy An anecdote… • Plans to expand to domain experts
- 16. Lesson Learned – Skills • Not as hard as we thought! • How the learning curve was reduced • Having a very short cycle (immediate) from rule writing to testing • RedPen technique for learning the syntax, especially on collections • Reporting to see all cases by risk/issue helped clinical team analyze and approve the rules • Decision Improvement • Based on analyzing decision results Clinical team now looking at offering more proactive issues identification for those nearing an issue identified status • Rules writing worked well with agile scrum methodology
- 17. Rules Design • Business changes • Over time • Per customer implementation • For example • From food pyramid • To food plate
- 18. Lesson Learned – Rules Design • Cascading decisions allow customization per health plan • Some customers choose to stay on food pyramid rather than move to food plate • Ability to add new fields as rules were added increased productivity since BA’s did not have to rely on IT • Easy to change decision flow and reorganize decision steps rules • Easily refactoring as needed as the number of rules increased through the sprints • IT/Rule Authoring team successfully worked in parallel w/ coordination around the data model
- 19. Deployment Architecture in flux at the start of the project Complete redesign of the infrastructure Made decision to decouple completely deployment from rules implementation And it worked!
- 20. Lesson Learned – Deployment • IT and Rules Teams can work mostly in parallel • Needs for coordination on the data model • Mitigated • Performance is not an issue, even on the cloud • Peak loads during enrollment Jan-Mar up to 1 million transactions per hour, 200 pages per min on web portal
- 21. Questions? Thank You! Carole-Ann Berlioz-Matignon Co-Founder & CPO Sparkling Logic CMatignon@SparklingLogic.com @CMatignon