clinical and care management (ccm) bps services - focus on exl · 2019. 10. 21. · coordination...
TRANSCRIPT
Copyright © 2019 Everest Global, Inc.
This document has been licensed for exclusive use and distribution by EXL
EGR-2019-20-E-3369
®
™
®
Clinical and Care Management (CCM) BPS Services
PEAK Matrix™ Assessment 2019
Focus on EXL
October 2019
2Copyright © 2019, Everest Global, Inc.
EGR-2019-20-E-3369
®
Introduction and scope
Everest Group recently released its report titled “Clinical and Care Management (CCM) BPS Services PEAK Matrix™ Assessment 2019”,
This report analyzes the changing dynamics of the CCM BPS landscape and assesses service providers across several key dimensions.
As a part of this report, Everest Group classified 16 service providers on the Everest Group PEAK Matrix™ for CCM BPS into Leaders, Major
Contenders, and Aspirants. The PEAK Matrix is a framework that provides an objective, data-driven, and comparative assessment of CCM
BPS providers based on their absolute market success and delivery capability.
Based on the analysis, EXL emerged as a Leader. This document focuses on EXL’s CCM BPS experience and capabilities and includes:
⚫ EXL’s position on the CCM BPS PEAK Matrix
⚫ Detailed CCM BPS profile of EXL
Buyers can use the PEAK Matrix to identify and evaluate different service providers. It helps them understand the service providers’ relative
strengths and gaps. However, it is also important to note that while the PEAK Matrix is a useful starting point, the results from the
assessment may not be directly prescriptive for each buyer. Buyers will have to consider their unique situation and requirements, and match
them against service provider capability for an ideal fit.
Source: Everest Group (2019) unless cited otherwise
3Copyright © 2019, Everest Global, Inc.
EGR-2019-20-E-3369
®
Background and methodology of the research
Background of the research
Clinical and care management can be defined as a set of activities that either directly impact the health outcome of the population / individual
(such as health risk assessment, case management, and medication adherence programs) or indirectly help healthcare organizations
provide quality care at lower cost (such as CAHPS and STAR / HEDIS).
While clinical and care management as a segment has existed for a while now, its importance has increased exponentially post ACA. With
the US already being the highest spender in the world on healthcare, ensuring care to reduce readmissions and claims denials is the need of
the hour. Also, with ACA shifting the focus from volume-based care to value-based care, the healthcare stakeholders are taking proactive
measures to ensure quality care at lower cost for members. This shift is supported by the seepage of consumerism in healthcare, motivating
the customers or members to be more involved in their care lifecycle. All this is putting pressure on the payers as well as providers to make
investments in clinical and care services and at the same time reduce their costs. With the stakeholders struggling to find the right talent,
domain, and technology expertise in house, they are looking for the outsourcing route to help them in their journey.
Such a scenario presents BPS providers with a host of opportunities; however, third-party vendors need to enhance investments in building
capabilities in areas such as consulting / design thinking, technology, and domain-led services to ensure they plug gaps where payers and
providers lack in-house capabilities.
Scope and methodology
In this research, we analyze the global healthcare clinical and care management BPS provider landscape. We focus on:
⚫ Relative positioning of 16 service providers on Everest Group’s PEAK Matrix™ for clinical and care management BPS
⚫ Analysis of service provider’s market share
⚫ Everest Group’s analysis of service providers’ strengths and areas of improvement
4Copyright © 2019, Everest Global, Inc.
EGR-2019-20-E-3369
®
Everest Group PEAK Matrix™ for CCM BPS – summary
Leaders
Accenture, Cognizant, and EXL
Major Contenders
CareCentrix, Change Healthcare, Conduent, DXC Technology, eQHealth Solutions, HGS, Magellan Health, Shearwater Health,
and WNS
Aspirants
Accolade, Health Dialog, Kepro, and Visionary RCM
Everest Group classified 16 CCM BPS providers on the Everest Group PEAK Matrix™ into the three categories of Leaders,
Major Contenders, and Aspirants. The PEAK Matrix™ is a framework to assess the absolute market impact and overall vision
and capability of service providers.
5Copyright © 2019, Everest Global, Inc.
EGR-2019-20-E-3369
®
™
®
Everest Group PEAK Matrix™
Clinical and Care Management (CCM) BPS Services PEAK Matrix™
Assessment 2019 | EXL positioned as Leader
High
Leaders
Major Contenders
Aspirants
Everest Group Clinical and Care Management (CCM) BPS Services PEAK Matrix™ Assessment 2019
Note 1 Service providers scored using Everest Group’s proprietary scoring methodology
Note 2 Assessment for Accolade, CareCentrix, Change Healthcare, Conduent, eQHealth Solutions, Health Dialog, Kepro, Magellan Health, and Visionary RCM excludes service provider
inputs on this particular study and is based on Everest Group’s estimates that leverage Everest Group’s proprietary Transaction Intelligence (TI) database, ongoing coverage of these
service providers, their public disclosures, and interaction with buyers. For these companies, Everest Group’s data for assessment may be less complete
Source: Everest Group (2019)
Vision & capability
(Measures ability to deliver services successfully)
Mark
et
Imp
act
(Measure
s im
pact cre
ate
d in t
he m
ark
et)
Low
High
LeadersMajor Contenders
eQHealth Solutions
Change Healthcare
DXC TechnologyConduent
CareCentrix
Magellan Health Shearwater Health
HGS
WNS
Accenture
Cognizant
EXL
Aspirants
Low
Visionary RCM
Health Dialog
Accolade
Kepro
6Copyright © 2019, Everest Global, Inc.
EGR-2019-20-E-3369
®
Recent acquisitions and partnerships
⚫ 2018: Acquired SCIO Health Analytics, a health analytics solution and
services company across health plans, PBMs, employers, health services,
and global life sciences companies
⚫ 2017: EXL developed CareRadius® Connect in partnership with Nuance®
Communications, a firm which delivers intelligent self-serve solutions
⚫ 2016: Acquired Datasource Consulting to expand its data management
and analytics capabilities
⚫ 2015: Entered into a partnership with Novu, a consumer engagement and
rewards platform, to enhance CareRadius® Suite’s capabilities
⚫ 2015: Acquired RPM Direct, a provider of database marketing, to
strengthen its analytics capabilities focused on insurance and healthcare
Recent developments
⚫ 2017: Investment in industry analytics solutions and technology enabled
services through SCIO acquisition and EXL Population Health Solutions to
help manage population risk and total cost of care. Incorporation of
advanced analytic technology, AI, NLP and digital intelligence
⚫ 2017: Investments in advanced automation, CareRadius®, and other
platform UX, as well as in additional healthcare-specific analytics solutions
⚫ 2017: Independent Health agreed to implement EXL’s CareRadius®
population health solution
Suite of services offered:
⚫ Utilization management
⚫ Care coordination
⚫ Population health management
⚫ Risk and compliance
Company profile: EXL is an operations management and analytics company that
provides operations management, decision analytics, and technology platforms to
organizations in insurance, healthcare, banking & financial services, utilities, travel, and
transportation & logistics, among others. EXL has been in business since 1999 and has
30,000+ professionals in locations throughout the United States, Europe, Latin America,
Australia, South Africa, and Asia.
Key Healthcare Leaders
⚫ Sam Meckey, EVP Head of Healthcare
⚫ Rose Higgins, SVP, GM Data & Analytics
⚫ Elizabeth Bigham, SVP, GM Clinical Services
⚫ Sherri Walsh SVP Operations and Chief Nursing Officer
⚫ Dennis Thomas, SVP, Clinical Services Delivery
Headquarters: New York, the United States
Website: www.exlservice.com
2016 2017 2018
Revenue (US$ million)1 36 48 63
Number of FTEs1 1,321 1,764 2,112
Number of clients1 15 16 61
1 Represents information for period ending December 31 of each year
EXL | CCM BPS profile (page 1 of 5)
Overview
7Copyright © 2019, Everest Global, Inc.
EGR-2019-20-E-3369
®
Westlake Village
Tampa
EXL | CCM BPS profile (page 2 of 5)
Key delivery locations
Chennai ManilaCebu
Alabang
Hartford
Bogota
Noida
8Copyright © 2019, Everest Global, Inc.
EGR-2019-20-E-3369
®
Key clinical and care management BPS engagements
Client name Processes served Region Client since
A leading US healthcare major Care coordination North America 2018
A leading US healthcare major Utilization management North America 2013
A leading national US healthcare payer Utilization management, care coordination, and risk & compliance North America 2011
Note: Based on contractual and operational information till December 2018
Clinical BPS FTE mix by segment
Number of FTEs
Clinical BPS FTE split by delivery location
Number of FTEs
Clinical BPS revenue mix by geography
Revenue in US$ million
100% = 2,112
60%12%
11%
6%
11%
100% = 2,112100% = 63
100%
11%
88%Care
coordination
Risk &
compliance
Population
health
management
North America
Offshore
Utilization
management
OnshoreOthers
EXL | CCM BPS profile (page 3 of 5)
Capabilities and key clients
Nearshore (1%)
9Copyright © 2019, Everest Global, Inc.
EGR-2019-20-E-3369
®
Solution name Processes served Year launched Description No. of BPS clients
CareConnect All
2014
CareRadius® Connect is an add-on module to the CareRadius® platform which
automates proactive member outreach to improve member reach, engagement and
outcomes.
1
SCIOVANTAGE®
Population health
management and care
coordination 2013
Analytics suite that connects disparate data, informs decisions to manage population
risk and achieve optimal outcomes. It helps understand member trends by cost,
quality and utilization, and segments members for effective engagement. It monitors
provider referral patterns, leakage and steer patients/members to top performers, and
tracks and manages program outcomes and ROI
15
CareAdviseTM All
2013
CareAdviseTM delivers the surveys, assessments and care plans for CareRadius®.
With CareAdviseTM, case managers can pose questions to members about the most
costly disease states and create evidence-based care plans that implement change
and improve outcomes for their members
2
Care Radius® All
2009
The CareRadius solution suite includes end to end care management/medical
management tools to manage member outreach and engagement coordinate all
clinical interventions and workflows, provider collaboration in care coordination,
reporting and compliance for commercial and government programs.
11
CareAffiliate® All
2009
CareAffiliate® offers providers a means for secure, automated web-based
communications with the care management organization by automating
communication and workflow between the care management organization, provider
community and member
9
SCIOCLARITY®
Risk and compliance
2006
A risk adjustment and quality solution that supports improved risk adjustment scores,
enhances quality ratings and helps ensure continuity of care. It provides actionable
information in managing patient populations and related RAF scores
32
EXL | CCM BPS profile (page 4 of 5)
Technology solutions/tools
10Copyright © 2019, Everest Global, Inc.
EGR-2019-20-E-3369
®
Strengths Areas of improvement
⚫ EXL has one of the most diverse delivery networks in the care
management services industry. It is one of the very few service providers
utilizing LATAM’s talent pool for processes such as medical reviews and
prior authorization
⚫ EXL is one of the very few players to have a automation and analytics
enabled platform solution, CareRadius®. Through the acquisition of
SCIO, it also has additional prospective clients to increase the penetration
of CareRadius®
⚫ Additionally, EXL has access to a lot of non-traditional data sources and
its strategy revolves around analytics, both as embedded and stand-alone
offerings. Its analytical capabilities have been further enhanced by SCIO
Health’s acquisition
⚫ Buyers highlighted domain expertise and relationship management with
different stakeholders such as procurement managers and business
heads as some of the key strengths of EXL
⚫ With most of the buyers demanding a partner in this industry over a
pure-play BPO vendor, EXL stands to gain by setting up a
consultative/advisory arm much like what it has done in P&C insurance
⚫ EXL should look to invest in building capabilities in population health
management, which is a growing area for outsourcing and is not as
saturated as utilization management.
⚫ End-clients want a stable management and EXL needs to be proactive
in allaying any fears in their mind, especially SCIO’s clients, about
delivery of services
Market impact Vision & capability
Market
adoption Portfolio mix Value delivered Overall
Scope of
services offered
Innovation and
investments
Delivery
footprint
Vision and
strategy Overall
Measure of capability: High Low
EXL | CCM BPS profile (page 5 of 5)
Everest Group assessment – Leader
11Copyright © 2019, Everest Global, Inc.
EGR-2019-20-E-3369
®
Appendix
12Copyright © 2019, Everest Global, Inc.
EGR-2019-20-E-3369
®
Everest Group’s view of the CCM BPS value chain
Clinical service desk
Note: This report covers vertical-specific BPO within the healthcare payer space. It does not include coverage of horizontal business processes such as F&A, HR,
procurement, and contact centers
Population health
managementCare coordination Risk and compliance
Utilization
management
Prior authorizationCare program
enrollment and referral
STAR/HEDIS reporting
and quality improvementPatient navigation
Medical data
management
Clinical decision support CAHPS supportNurse triageDisease/case
managementHealth risk assessment
Risk adjustmentMedical necessity review Medication adherence TelemedicineSocial Determinants of
Health (SDOH)
Prospective, concurrent,
and retrospective review
Wellness and lifestyle
management programs
Patient/physician
education
13Copyright © 2019, Everest Global, Inc.
EGR-2019-20-E-3369
®
™
®
Everest Group PEAK Matrix™ is a proprietary framework
for assessment of market impact and vision & capability
Everest Group PEAK Matrix
Vision & capability
Measures ability to deliver services successfully
High
Low
Low High
Leaders
Aspirants
Ma
rke
t im
pa
ct
Measure
s im
pact cre
ate
d in t
he m
ark
et
Major Contenders
14Copyright © 2019, Everest Global, Inc.
EGR-2019-20-E-3369
®
™
®
Services PEAK Matrix™ evaluation dimensions
Measures impact created in the market –
captured through three subdimensions
Market adoption
No. of clients, revenue base, and
YOY growth, deal value/volume
Portfolio mix
Diversity of client/revenue base
across geos and type of
engagements
Value delivered
Value delivered to the client
based on customer feedback
and transformational impact
Vision and strategy
Vision for the client and itself;
future roadmap and strategy
Scope of services offered
Depth and breadth of services
portfolio across service sub-
segments / processes
Innovation and investments
Innovation and investment in the
enabling areas, e.g., technology
IP, industry/domain knowledge,
innovative commercial
constructs, alliances, M&A, etc.
Delivery footprint
Delivery footprint and global
sourcing mix
Measures ability to deliver services successfully.
This is captured through four subdimensions
Mark
et
imp
act
Vision & capability
Major Contenders
Leaders
Aspirants
15Copyright © 2019, Everest Global, Inc.
EGR-2019-20-E-3369
®
FAQs
Does the PEAK Matrix™ assessment incorporate any subjective criteria?
Everest Group’s PEAK Matrix assessment adopts an unbiased and fact-based approach (leveraging service provider / technology vendor RFIs and
Everest Group’s proprietary databases containing providers’ deals and operational capability information). In addition, these results are validated /
fine-tuned based on our market experience, buyer interaction, and provider/vendor briefings
Is being a “Major Contender” or “Aspirant” on the PEAK Matrix, an unfavorable outcome?
No. The PEAK Matrix highlights and positions only the best-in-class service providers / technology vendors in a particular space. There are a number of
providers from the broader universe that are assessed and do not make it to the PEAK Matrix at all. Therefore, being represented on the PEAK Matrix is
itself a favorable recognition
What other aspects of PEAK Matrix assessment are relevant to buyers and providers besides the “PEAK Matrix position”?
A PEAK Matrix position is only one aspect of Everest Group’s overall assessment. In addition to assigning a “Leader”, “Major Contender,” or “Aspirant” title,
Everest Group highlights the distinctive capabilities and unique attributes of all the PEAK Matrix providers assessed in its report. The detailed metric-level
assessment and associated commentary is helpful for buyers in selecting particular providers/vendors for their specific requirements. It also helps
providers/vendors showcase their strengths in specific areas
What are the incentives for buyers and providers to participate/provide input to PEAK Matrix research?
⚫ Participation incentives for buyers include a summary of key findings from the PEAK Matrix assessment
⚫ Participation incentives for providers/vendors include adequate representation and recognition of their capabilities/success in the market place,
and a copy of their own “profile” that is published by Everest Group as part of the “compendium of PEAK Matrix providers” profiles
What is the process for a service provider / technology vendor to leverage their PEAK Matrix positioning and/or “Star Performer” status ?
⚫ Providers/vendors can use their PEAK Matrix positioning or “Star Performer” rating in multiple ways including:
– Issue a press release declaring their positioning. See citation policies
– Customized PEAK Matrix profile for circulation (with clients, prospects, etc.)
– Quotes from Everest Group analysts could be disseminated to the media
– Leverage PEAK Matrix branding across communications (e-mail signatures, marketing brochures, credential packs, client presentations, etc.)
⚫ The provider must obtain the requisite licensing and distribution rights for the above activities through an agreement with the designated POC at
Everest Group.
Does the PEAK Matrix evaluation criteria change over a period of time?
PEAK Matrix assessments are designed to serve present and future needs of the enterprises. Given the dynamic nature of the global services market and
rampant disruption, the assessment criteria are realigned as and when needed to reflect the current market reality as well as serve the future expectations
of enterprises
About Everest Group
Everest Group is a consulting and research firm focused on strategic IT, business
services, and sourcing. We are trusted advisors to senior executives of leading
enterprises, providers, and investors. Our firm helps clients improve operational
and financial performance through a hands-on process that supports them in making well-
informed decisions that deliver high-impact results and achieve sustained value. Our
insight and guidance empower clients to improve organizational efficiency, effectiveness,
agility, and responsiveness. What sets Everest Group apart is the integration of deep
sourcing knowledge, problem-solving skills and original research. Details and in-depth
content are available at www.everestgrp.com.
®
Social Media
@EverestGroup
@Everest Group
Stay connected
Website
www.everestgrp.com
Blog
www.everestgrp.com/blog/
Dallas (Headquarters)
+1-214-451-3000
Bangalore
+91-80-61463500
Delhi
+91-124-496-1000
London
+44-207-129-1318
New York
+1-646-805-4000
Toronto
+1-416-388-6765
This document is for informational purposes only, and it is being provided “as is” and “as available” without any warranty of any kind, including any warranties of completeness, adequacy, or fitness for a particular purpose. Everest Group is not a legal or investment adviser; the contents of this document should not be construed as legal, tax, or investment advice. This document should not be used as a substitute for consultation with professional advisors, and Everest Group disclaims liability for anyactions or decisions not to act that are taken as a result of any material in this publication.