Healthesystems

Sandy Shtab, Assistant Vice President Advocacy & Compliance, Healthesystems, provided both video and written responses to the Member Spotlight questions. Please enjoy learning more however you choose! 

IAIABC: Please provide a profile of your organization.

Sandy Shtab: Healthesystems was founded in 2002 to solve what was at the time a big problem for the payer community. There was no system in place where payers could integrate all prescription activity on a claim, whether the drug was dispensed by a retail pharmacy, mail order or out of network. Our founder, Ron Roma developed an automated solution which unified this data into a single patient profile. By doing so payers were able to improve patient care and control costs through real time oversight of both drug utilization and spend. It was a unique to the marketplace solution at the time, and since those early days, Healthesystems has expanded our service offerings to include more innovative services that incorporate clinical oversight and network management tools that help our customers make more informed decisions about patient care, vendor performance and overall claim outcomes.

IAIABC: How does your organization serve the workers' compensation industry or what do you see as the most important role you play in the workers' compensation industry? 

SS: Healthesystems is transforming the way healthcare is delivered. It’s no secret that our healthcare system is difficult to navigate, even for people who are very well versed in healthcare and insurance. We are helping to ease that process by putting the patient at the center of care, giving payers a holistic view on each injured worker. We help speed the delivery of care and give the payer insight to the providers’ overall performance.

IAIABC: What do you see as some of the major challenges the industry is facing and how can we as a community address them?

SS: The pace of change as it relates to technology in our healthcare system and how we manage claim and medical data is a challenge. We need to speed up our ability to take in vast amounts of data and leverage new ways of interacting with that information. This is something that workers’ compensation industry has difficulty doing, because it’s such a complex system with very little interoperability today. There are disparate systems that do not communicate with each other very well. Administrative simplification is something we long for and talk about all the time, but progress towards adoption has been slow. Everyone supporting the injured worker must work within this system that has not evolved much in the last 40-50 years. We need to promote interoperability and find ways to make the process easier for everyone involved.

IAIABC: Are there any projects/programs/initiatives going on at your organization that you are particularly excited or enthusiastic about?

SS: The tools we’ve developed and continue to develop that help adjusters serve the injured worker are improving the claim experience and that translates to better outcomes for injured workers. The amount of information an adjuster has coming at them is so difficult to manage, let alone analyze and action. We’re helping claims professionals to do that by expanding the traditional view of risk beyond what’s in the claim file on their desktop. We are using advanced analytics to give adjusters a view into the impact of the swing factors in a claim, things like comorbidities, medication adherence, mental health exposures, fraud, waste & abusive billing practices. It’s difficult for adjuster to be looking at all these things while their email is blowing up and their phone is ringing off the hook. So we strive to put this data together to make their job easier, whether it’s through dashboards, data visualizations, even the ability to look at real time information about their pharmacy or physical therapy treatment effectiveness. This is stuff no one else is doing in the marketplace. 

IAIABC: Why is your organization a member of the IAIABC? What would you tell others about the benefits of membership?

SS: Healthesystems has been a member of IAIABC since 2008. We first joined to better understand the EDI state reporting requirements, but quickly learned there is a lot more to IAIABC than EDI. The medical issues committee and the research and standards committee are great environments to collaborate and learn from industry experts, and of course the number of regulators who attend is unmatched by any other event. I’ve been fortunate to be a part of the IAIABC Associate Members’ Council, representing PBM members. I’m so grateful that IAIABC provides the forum for all of us to learn from each other.