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Healthcare Payers - Buy Rules Now or take the consequences!

Joanne Galimi a Research Director with Gartner Group has released a couple of interesting papers - "Rule Management Is the Next Major Business and IT Challenge for Healthcare Payers" and "Findings From the Gartner 2006 Global Research Meeting: Tactical BPM Approaches Will Cause Rule Management Nightmares for Healthcare Payers"

These reinforce the value of business rules for healthcare payers - a trend I am already seeing big time. Some pertinent quotes from the reports:

"This increase in business change is leading to the use of business rule engines by payers to achieve operational efficiency and ultimately business agility. The benefits of an agile business rule architecture are grossly underestimated from business and technical perspectives. "

She predicts that by 2010, healthcare payers will double the use of business rule engines. I completely agree with her assessment and would add that consistency (enabling cheaper compliance and fewer errors) is the other key benefit of a business rules approach. she identifies a number of areas where rules will have significant impact, one of which is in member management, something I did a webinar about with Health Data Management recently. We also see growing interest in claims as well as the use of predictive analytics with rules for fraud detection, for instance.

In the second piece she says

"Healthcare payers continue to make tactical purchasing decisions for business process management offerings. This approach will cause short- and long-term challenges unless payers craft strategies to integrate rule management across applications and multiple rule engines."

She advises Healthcare payers seeking to deploy business process management to

"plan to standardize (where possible) multiple rule engines and manage externalized rules to avoid redundancy and inconsistency. "

I could not agree more. I see this a lot - tactical BPM decisions (or CRM decisions or other system decisions) resulting in rules being automated piecemeal instead of being turned into the corporate asset they could be. I think BPM and BRM (Business Rules Management) are very complementary but rules don't only get deployed into business processes. Getting this right requires a focus on decisions not just on processes. As one of the founders of Fair Isaac said many years ago "grab the decision by the throat and don't let go".

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