In a healthcare marketplace teeming with pharmacy benefit managers (PBM), utilization managers (UM), and other niche health and wellness vendors, payers and TPAs must be able to integrate with a patchwork of legacy and modern systems.
Their tech stacks must be flexible and adaptable enough to accommodate the diversity of APIs, data structures, and integration standards, especially given the sheer number and variability of plan stack vendors. They must build and maintain a complex web of data integrations to support eligibility, claims, pre-authorizations, accumulators, and other core operational processes.
Traditionally, this required overcoming several significant challenges. Legacy healthcare interfaces are inflexible and poorly understood, making it challenging for payers and TPAs to interoperate. Building integrations for a complex data trade could easily take hundreds of engineering hours, with integrations involving legacy or proprietary systems requiring even more.
Until recently, there just weren’t any good options. General-purpose API orchestration platforms provide a framework for creating integrations, but lack built-in logic designed specifically for healthcare, forcing payers and TPAs to build and maintain this logic themselves. This means that instead of focusing on value-creating work—like optimizing claims-processing logic or improving predictive analytics for cost management—technical experts squander time maintaining the status quo.
Four Essential Business Drivers for Modernization
By migrating to a modern, cloud-native integration platform, payers and TPAs can ensure data trades aren’t just reliable and performant, but easier to set up, too—and that the integrations supporting them are less costly to maintain.The following are four of the most compelling business modernization drivers for payers and TPAs:
- Rapid setup, simplified maintenance - Modernizing on a cloud SaaS or PaaS solution accelerates time to value, eliminating many of the challenges involved in operating a data integration platform. And because it embeds healthcare-specific logic, a cloud data integration platform significantly reduces the time payers and TPAs spend configuring data integrations, enabling them to rapidly onboard new plan stack vendors. Just as important, a cloud-native integration platform lightens the maintenance load; for many payers and TPAs, the cost of maintaining the integrations supporting data trades rivals or exceeds that of engineering them.
- Automate for agility - Manual or ad hoc, script-driven methods are prone to error and do not scale. Automation is the answer—the linchpin of interoperability in modern, cloud-native software architecture. Automation is used to enforce schema and formatting standards, as well as to validate data types during trades. It is essential in trading scenarios that require bi-directional, low-latency data syncing between parties. Beyond that, automation helps simplify API integrations; is used to encrypt data in all stages of processing; supports compliance by generating logs and audit trails; and is the engine of the event-driven interventions, like alerts, that payers and TPAs depend on to detect anomalies or opportunities to drive better outcomes.
- Do more with less - Payers and TPAs are operating under tight budgets and face immense pressure to do more with less. Resource constraints mean that every investment, whether in infrastructure or talent, needs to yield demonstrable ROI. There’s also an arms race, with payers and TPAs competing for data engineers, data scientists, and other technologists. They need “smart” software that boosts the productivity of the experts they do have, freeing them to create value—instead of merely keeping the lights on.
- Revamp your security posture - Legacy data integrations usually involve a mix of old and new technologies, some of which are no longer maintained. Custom-built integrations may rely on a hodgepodge of solutions or cloud services, scripts, job scheduling tools, and other software. With both approaches, ensuring a robust, consistent security and compliance posture is extremely challenging. The people who designed and implemented them have likely moved on. When new vulnerabilities are discovered, there might not be a vendor or community to step up and provide patches. And in most cases, these integrations weren’t designed with monitoring and observability in mind, compromising both security and compliance. Cloud infrastructure and modern, cloud-native software are not only regularly supported and updated but also designed with built-in monitoring and observability, simplifying security and compliance.
Key Priorities for Data Integration Modernization
Legacy data integration platforms can be stumbling blocks in today's rapidly evolving healthcare marketplace. With new plan stack vendors appearing almost every week, payers and TPAs are starting to feel squeezed. The challenge is to quickly and reliably integrate with new providers, enabling them to create and administer custom-tailored health benefit plans for their customers. This isn’t a question of ripping and replacing legacy systems, but of augmenting them—with modern, cloud-native technologies that make it easier for payers and TPAs to rapidly design, test, and operationalize new integrations.
The path to modern dataflows and processes won’t look the same for all payers and TPAs. Nevertheless, there are five priorities that are integral to any modernization effort.
Cloud-first, cloud-native
Payers and TPAs must embrace a cloud-first, cloud-native integration strategy. Thanks to scalable cloud infrastructure, cloud-native platforms adapt seamlessly to unpredictable spikes in data traffic. Thanks to robust cloud encryption and security services, healthcare data is protected in all stages of processing. And by exposing a standard set of APIs and tools, it’s much easier to onboard new data sources.
Integration must be bi-directional
Think of it as reverse ETL, if you like: legacy or custom-built systems are typically unidirectional, with data flowing from an upstream source to a specific destination. Bidirectionality allows payers or TPAs to simultaneously send and receive data trades for eligibility, claims, and other processes, eliminating the need for a patchwork of complicated data integration and synchronization logic.
Adaptive data exchange
Payers and TPAs must be able to seamlessly accommodate different modes of data exchange, from traditional batch processing to the firehose of streaming data, to API-based exchange. Batch will always be important, but payers and TPAs need to ingest streaming data to process time-sensitive information about claim status, patient eligibility, or authorization determinations, while API-based integration is becoming increasingly common, too.
Observability is non-negotiable
A core component of a modern data integration platform is observability. By permitting real-time insight into data trades, observability technology enables payers and TPAs to proactively detect errors and inconsistencies. Combined with automated features that validate mapping logic and check syntax, this accelerates the design, testing, and optimization of integrations. Plus, built-in observability features not only enable payers and TPAs to target and meet aggressive SLAs for timely data exchange, but also help them rapidly and reliably onboard new plan stack vendors.
Efficiency is key
Data exchange is not just about speed; it's about accuracy, timeliness, and efficiency, too. Support for incremental trades should be a standard feature of any modern data integration platform, enabling payers and TPAs to create fast, efficient dataflows that transfer only new or changed data. However, because identifying and reconciling incremental changes is especially challenging in the healthcare setting, most products rely on less efficient methods, like fixed time windows, or batch intervals, instead.
Keep it simple, healthcare is already complex enough
The challenges payers and TPAs face are daunting enough, the quirks or limitations of a data integration platform shouldn’t add to them. Modernizing on a cloud-native data integration platform is a matchless opportunity to eliminate technical debt—at once simplifying, and leveling up, your data infrastructure.
Five Reasons Flume is the Best Choice for Your Healthcare Data Integration Platform
Flume is purpose-built to tackle the complex data integration challenges faced by payers and TPAs, facilitating seamless data trades among healthcare providers, PBMs, and other entities. It’s a best-in-class solution, designed for healthcare payers and TPAs, that reduces the overhead involved in operating a data integration platform. Flume ensures security, simplifies compliance and significantly reduces costs.
Here are the top six reasons why Flume is the go-to choice for your healthcare data integration needs.
- Get started fast, integrate rapidly, repeatably, and reliably - Payers and TPAs are finding it almost impossible to keep up with the proliferation of new plan stack vendors. Integrating with each vendor means mapping to its specific schema and formats, designing and testing ETL processes, setting up and validating API calls, designing and implementing data validation and quality checks, and performing dozens of other tasks. Not least, it involves verifying everything that’s been done adheres to regulations, best practices, and governance standards. This is a tedious enough process in most verticals; in healthcare, it can sometimes feel like a Sisyphean undertaking. What sets Flume apart is exceptional time to value. With its built-in rules and logic, best-in-class observability capabilities, and automated mapping, transformation, and validation features, Flume radically reduces the time it takes to design, test, and operationalize healthcare data integrations.
- Leave the operating to us - Flume is a fully managed data integration platform, so you don’t have to worry about scaling or operating it. Designed for payers and TPAs, Flume is the culmination of decades of expertise in healthcare data exchange, providing out-of-the-box data integration, security, and compliance features designed to exacting healthcare standards. Most importantly, Flume eliminates the burden of operating and maintaining a data integration platform, significantly reducing technical debt.
- Modernize pragmatically - Flume allows you to take a phased approach to modernizing your healthcare data integrations. You can start small, with just a few integrations, and grow or expand as needed. Flume can coexist with your existing integration processes or tools, enabling you to migrate in a phased manner. Finally, if you’ve standardized on an API management platform like Mulesoft, or an orchestration platform like Apache Airflow, Flume doesn’t force you to make a zero-sum choice. You can continue using these platforms to support your other workloads, offloading your healthcare-specific integrations to Flume.
- Put domain experts in the driver’s seat - Domain experts will thrive using Flume's intuitive self-service design environment to create and manage the complex integrations payers and TPAs use to support benefits, eligibility, and other core processes—with very little technical expertise required. Flume radically accelerates the data integration design phase by putting design capabilities in the hands of the people who understand healthcare and its complicated rules, and by validating integrations to ensure they work as intended. This frees up data engineers, programmers, and other technical experts to focus on value-creating work.
- Level up for real-time - With built-in, robust support for streaming data, Flume enables real-time data exchange. The mechanics of integrating streaming data are complex. Still, for time-sensitive scenarios like claim verification, authorization determinations, or patient eligibility checks, the ability to ingest and process data from plan stack vendors at low latencies enables payers and TPAs prevent to payment discrepancies and eliminate mistakes—as when patients receive services they aren’t eligible for—or are denied services they should receive. Flume's ability to support bidirectional streaming is a best-in-class feature that payers and TPAs could easily spend hundreds of thousands of dollars building and maintaining on their own.
Speaking of which…
- Avoid costly DIY engineering - Flume is the product of tens of thousands of engineering hours and embodies the expertise of hundreds of domain experts. Its best-in-class features — pre-built rules and integration logic, support for both bi-directional and real-time data exchange, and observability capabilities — were designed specifically for payers and TPAs. Building a similar platform from scratch, using general-purpose tools like MuleSoft or Airflow, could cost hundreds of thousands or even millions of dollars—just to start. Operating and maintaining this platform could cost tens or even hundreds of thousands of dollars annually. Flume gives you access to technology worth millions of dollars at a subscription price.
Find out why more Payers are choosing Flume to accelerate and simplify data integration.to learn more.
