TriZetto Value-Based Benefits Solution Enables Customization of Incentive Programs, Automation of Member-Compliance Proces

Optional Diabetes, Asthma, and Health and Wellness Benefit Guides Help Health Plans and Employer Groups Improve Member Health

GREENWOOD VILLAGE, Colo.--(BUSINESS WIRE)-- The TriZetto Group, Inc. today announced the launch of the new version of the TriZetto® Value-Based Benefits Solution, available to health plans that use the company’s enterprise core platforms to provide coverage for more than a third of all Americans. The new release enables healthcare payers and self-insured employers to further customize member-incentive programs; automate the member-compliance process; modify a member’s cost-share without changing the subscriber’s health plan; and use optional templates to streamline claims adjudication and incentive and reward administration specifically for diabetes and asthma patients and workplace health and wellness programs.

The Value-Based Benefits Solution is a patent-pending, end-to-end solution for the design and management of value-based insurance design (VBID) programs. TriZetto’s solution provides a platform for sharing data between the employer, health and wellness vendor, reward vendor, payer, and member.

“Faced with healthcare costs that continue to rise even as health outcomes fail to improve, many in the industry are taking note of the growing body of evidence that shows better clinical outcomes from VBID,” said Jeff Rideout, M.D., senior vice president and chief medical officer at TriZetto. “The new version of the TriZetto Value-Based Benefits Solution helps improve outcomes with enhanced capabilities that support three key tenets of sound design – member engagement, design effectiveness and administrative efficiency.

The more a VBID program can target specific conditions and specific member needs, the more it can improve patient care and overall value. The newest version of our Value-Based Benefits Solution continues to drive that type of specificity.”

The new release also provides additional flexibility in program design and automation, allowing payers to define required member activities with multiple levels of compliance; issue unique rewards that include lower member costs; automate processes that identify instances of member compliance; and enhance member-communication capabilities. Streamlining the identification of member compliance is “where the rubber meets the road,” according to Katie Neben, TriZetto’s director of VBID product management, and the new version of TriZetto’s solution adds functionality that automates the identification of reward-worthy activities by evaluating medical claims, pharmacy claims or biometric data. These capabilities reduce the administrative burden of managing compliance and rewards.

“The Value-Based Benefits Solution enables payers to specify steps toward compliance that members must take to earn rewards, build rules that identify instances of member compliance, automate the issuance of member-specific rewards, and present members with content that explains the entire process and what to expect,” Neben said. “For instance, a payer and its employer customer might want to reward diabetics for receiving clinically appropriate services such as office check-ups and blood tests. The TriZetto Value-Based Benefits Solution enables the health plan to define the compliance rules based on the diagnosis and procedure information that must appear on medical claims to identify those members who should receive rewards.”

A key test of any value-based product is its ability to enable payers to automate, to the degree possible, clinically recommended designs that drive members’ healthy behavior and support the management of their chronic diseases. TriZetto has teamed with the Value-Based Insurance Design Institute (VBIDI) to offer optional VBID Benefit Guides that provide details of the clinical services that members should receive to manage diseases, actions members should be incented to undertake, and all the clinical and system codes required to configure these programs both within the Value-Based Benefits Solution and TriZetto’s FacetsTM and QNXTTM enterprise core administration systems. The guides will make it even easier and faster for TriZetto’s customers to implement and configure value-based benefits for their populations.

The first three VBID Benefit Guides include diabetes, asthma, and health and wellness for men, women and children. Additional guides for conditions such as hypertension, heart disease and depression are under development and will roll out this year. Developed with professors A. Mark Fendrick, M.D., and Michael Chernew, Ph.D., of VBIDI, the optional guides are based on medical literature and, where possible, evidence-based guidelines, providing strong clinical efficacy.

“The VBID Benefit Guides are timely, with momentum building for value-based healthcare,” said Fendrick. “It’s exciting to see that the program designs that we recognize as clinically appropriate can be automated and fully supported by the TriZetto Value-Based Benefits Solution.”

TriZetto last year announced its partnership with Fendrick and Chernew, acknowledged founders of the VBID movement, to develop chronic-condition templates as options for healthcare payer customers of its Value-Based Benefits Solution. More than a decade of case studies shows that by lowering co-pays or coinsurance for necessary, effective medical services and drugs that treat chronic conditions, VBID can improve patient health and reduce more expensive, acute care.

Policymakers inside the beltway in Washington, D.C., have taken note, as well.

In a March 2011 report to Congress, the U.S. Department of Health & Human Services wrote, “Some employers and private health plans already use the evidence-based programs to promote better health. Similar approaches can improve adherence to recommended medications, which many Americans fail to take, often due to cost. At the federal level, HHS is promoting value-based insurance models.”1

Echoed Don Berwick, M.D., administrator of the Centers for Medicare & Medicaid Services: “Investing in prevention makes financial sense, too. That’s especially true for secondary prevention – preventing deterioration in chronic illness. As much as three-quarters of the $2.5 trillion-plus that we spend on U.S. healthcare each year goes to paying the bills for chronic illness.”2

Further, the Medicare Payment Advisory Commission, an independent congressional agency, encouraged the coupling of value-based benefits with value-based provider reimbursement, stating, “Raising or lowering copayments for a service would have more effect on utilization if the incentive created for beneficiaries is aligned with that for physicians.”3

About TriZetto

TriZetto provides world-class healthcare IT software and service solutions, including patented and patent-pending innovations, that drive administrative efficiency, improve the cost and quality of care, and increase payer and provider collaboration and connectivity. TriZetto’s solutions touch half of the U.S. insured population and reach more than 21,000 physician practices representing more than 75,000 practitioners. The company’s payer offerings include enterprise and component software, application hosting and management, business process outsourcing services and consulting that help transform and optimize operations. TriZetto’s provider offerings through Gateway EDI, a wholly owned subsidiary, include advanced tools and proactive services to monitor, catch and fix claims issues before they can impact a practice. TriZetto’s integrated payer-provider platform will enable the deployment of promising new models of post-reform healthcare. TriZetto is committed to the integration and convergence of technology systems that enable its vision of Integrated Healthcare Management, the coordination of benefits and healthcare to drive more value from every healthcare dollar spent. For more information, visit


1. “Report to Congress: National Strategy for Quality Improvement in Health Care,” U.S. Department of Health and Human Services, March 21, 2011.

2. Public information posting, Donald Berwick, M.D., CMS administrator,, June 21, 2011.

3. “Report to the Congress: Medicare and the Health Care Delivery System,” Medicare Payment Advisory Commission, June 2011.


The TriZetto Group
Loren Finkelstein, 303-542-2460
[email protected]
Schwartz Communications
Davida Dinerman, 781-684-0770
[email protected]

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