Q&A: How Can Payers Sustain Optimization Improvements?

In our previous Q&A, we explored where health plans should start with operational optimization. For many organizations, the answer is a focused, workflow-based approach that targets a specific operational challenge and delivers measurable results. 

But achieving an initial improvement is only part of the equation. The bigger challenge is sustaining that improvement over time. How can health plans maintain momentum, continue driving value, and ensure that operational gains become part of the organization’s day-to-day performance?

To continue our conversation on payer operations and optimization, we asked Tegria Managing Director Gary Mirka about one of the most common challenges health plans face: maintaining momentum after an improvement initiative is complete.

Q: Why do some optimization initiatives lose momentum after they begin?

One common challenge is that organizations successfully complete the initial project but never fully operationalize the changes. Mirka has seen this pattern throughout his career: A new capability is implemented, a workflow is improved, or a process is redesigned. The project team moves on, operational priorities shift, and the broader adoption effort stalls.

“Sometimes once the consultant leaves, the project stops,” Mirka said. “The intention is that the business teams will continue to roll out additional capabilities or workflows, but often that doesn’t happen.” As a result, organizations may realize some value from an initiative while leaving additional opportunities untapped.

Q: What does successful adoption look like?

Successful adoption happens when operational improvements become part of the organization’s normal way of working. That means teams are not only using new workflows but also measuring performance, monitoring outcomes, and continuously refining processes over time.

According to Mirka, organizations often focus heavily on implementation activities while spending less time defining how success will be measured after go-live. The most successful organizations establish clear operational goals from the beginning and continue monitoring performance long after the initial work is complete.

Q: What role do metrics play in sustaining improvements?

Metrics are foundational. One of the first questions Mirka asks organizations is how they currently measure operational performance.

“A lot of organizations don’t necessarily have consistent metrics around turnaround time, defect rates, testing quality, or operational performance,” he said.

Without those measurements, it becomes difficult to determine whether a process is improving, remaining stable, or drifting backward over time.

Examples of useful operational metrics may include:

The specific measures will vary by operational area, but the principle remains the same: Organizations need visibility into performance if they want to sustain improvement.

Q: How does governance support long-term success?

Governance helps organizations move from one-time projects to ongoing operational excellence. While governance can mean different things across organizations, Mirka believes it starts with accountability and visibility.

Leaders need to understand:

• What outcomes they are trying to achieve 

• How performance is being measured 

• Who is responsible for maintaining results 

• When intervention is needed 

Without that structure, even well-designed improvements can gradually lose effectiveness as priorities shift and teams change. Governance also creates a framework for evaluating future opportunities and determining where optimization efforts should focus next.

Q: Should health plans think about optimization as a continuous process?

Absolutely. Mirka encourages organizations to view operational optimization as an ongoing discipline rather than a one-time initiative.

Many health plans have multiple opportunities to improve operational performance across claims, enrollment, provider configuration, prior authorization, and other functional areas. Rather than attempting to address everything at once, successful organizations often focus on one opportunity, demonstrate measurable value, and then build on that success.

“I like the idea of solving one problem, demonstrating value, and then using that momentum to identify the next opportunity,” he said.

This approach helps organizations steadily improve performance while minimizing disruption to day-to-day operations.

Q: What advice would you give payer leaders who want to sustain improvements over the long term?

Start by making performance visible. Organizations that consistently improve operational performance understand how their teams are performing, where bottlenecks exist, and what success looks like.

From there, focus on creating a culture of continuous improvement. Encourage teams to evaluate workflows regularly, monitor operational metrics, and look for opportunities to simplify processes or improve outcomes.

Most importantly, don’t treat optimization as something that ends when a project closes. The organizations that see the greatest long-term value are often the ones that continue asking questions, measuring results, and refining operations long after the initial work is complete.

Looking Ahead

Optimization is not a destination. It is an ongoing process of improving performance, adopting capabilities more effectively, and ensuring that operational teams have the tools, visibility, and governance needed to succeed.

For health plans facing increasing pressure to improve efficiency, manage costs, and respond quickly to changing market demands, the ability to sustain improvements may ultimately be just as important as identifying them in the first place.

Together, these conversations have explored three important questions facing payer organizations today:

• Are you getting full value from your core systems? 

• Where should you start with operational optimization? 

• How can you sustain improvements over time? 

While every organization’s path is different, the common thread is a focus on measurable outcomes, operational visibility, and continuous improvement.