{"id":5985,"date":"2024-12-09T20:42:39","date_gmt":"2024-12-09T20:42:39","guid":{"rendered":"https:\/\/www.horsesforsources.com\/?p=5985"},"modified":"2024-12-09T20:42:39","modified_gmt":"2024-12-09T20:42:39","slug":"the-decline-of-commercial-payers-is-an-opportunity-to-address-new-markets_120924","status":"publish","type":"post","link":"https:\/\/www.horsesforsources.com\/the-decline-of-commercial-payers-is-an-opportunity-to-address-new-markets_120924\/","title":{"rendered":"The decline of commercial payers is an opportunity to address new markets"},"content":{"rendered":"

Global<\/span> coverage for healthcare continues to shift away from commercial underwriting to <\/span>governments as the quadruple aim of care <\/span>(cost of care, experience of care, health outcome, and health equities)<\/span> is challenged.<\/span> This shift <\/span>indicates<\/span> a complex set of challenges and<\/span> opportunities across the market, making a clarion call for <\/span>a new generation of disruptors and innovators.<\/span><\/span>\u00a0<\/span><\/p>\n

In th<\/span>e <\/span><\/span>HFS Horizon:<\/span><\/span> Healthcare payer service providers, 2024<\/span><\/span><\/a> study, we evaluated <\/span>45<\/span> service providers for their ability to address the cost <\/span>of care<\/span> (Horizon 1), experience<\/span> of care<\/span> (Horizon 2), and health outcomes (Horizon 3) for health consumers globally.<\/span> We also began to explore service providers<\/span>‘ efforts<\/span> to <\/span>address health equities. This study <\/span>reflects inputs from <\/span>more than <\/span>300<\/span> healthcare enterprises, <\/span>over 80 enterprise references, and <\/span>approximately 80 supplier partners.<\/span><\/span>\u00a0<\/span>\u00a0<\/span><\/p>\n

45 service providers reflecting a variety of heritages attempt to address the quadruple aim of care<\/span><\/span>\"\"<\/span><\/h3>\n

It\u2019s a jungle out there, with new big game that\u2019s been ignored in the past\u00a0<\/span><\/span><\/span><\/h3>\n

The <\/span>significant<\/span> legacy commercial group insurance that contributed <\/span>to <\/span>h<\/span>igh margin<\/span>s<\/span> continues to<\/span> declin<\/span>e<\/span>.<\/span> Medicaid <\/span>lives<\/span> are plateauing, Medicare reimbursements are declining, <\/span>and<\/span> ASO is under unprecedented pressure as employers seek other avenues for services.<\/span> S<\/span>o, <\/span>h<\/span>ealth plans <\/span>have increased<\/span> outsourcing and offshoring to overcome their financial challenges<\/span>,<\/span> driving service provider growth. <\/span>Outsourced services<\/span> include new (health equity) and traditional (customer service)<\/span> services<\/span>. <\/span>Service providers are also exploring new<\/span>er insurance markets in the <\/span>Middle E<\/span>ast and Latin America as they <\/span>optimize<\/span> their value proposition and diversif<\/span>y<\/span> their <\/span>revenue mix.<\/span><\/span>\u00a0<\/span><\/span><\/p>\n

Costs and margins will headline the story <\/span>more prominent<\/span>ly<\/span> than before<\/span><\/span>\u00a0<\/span><\/span><\/span><\/span><\/h3>\n

Large<\/span> to mid-sized vertically integrated healthcare enterprises are reflecting 1-3% margins<\/span>,<\/span> while stand-alone health plans are showing closer to 1% margins<\/span>,<\/span> which is not sustainable or acceptable to their stakeholders.<\/span> Despite<\/span> the top-<\/span>line growth reflected by service providers, they will see margin deterioration over the next three years<\/span> regardless of <\/span>claims that AI will <\/span>aid in margin expansion. Th<\/span>at tech<\/span>–<\/span>enabled growth<\/span> movie has been played out in the past under banners such as <\/span>a<\/span>utomation and RPA.<\/span><\/span>\u00a0<\/span><\/span><\/span><\/p>\n

Bigger <\/span>ain<\/span>\u2019<\/span>t<\/span> better\u2026<\/span> a lesson that <\/span>remains<\/span> unlearnt<\/span><\/span>\u00a0<\/span><\/span><\/span>\u00a0<\/span><\/span><\/span><\/span><\/h3>\n

Top-line and bottom-line challenges have forced more than 50% of health plans to <\/span>acquire<\/span> non-similar businesses <\/span>such as <\/span>health systems, pharmac<\/span>ies<\/span>, <\/span>and <\/span>health services<\/span>. There ha<\/span>ve<\/span> been signs of <\/span>some successful financial integration<\/span>,<\/span> though not consistently,<\/span> but<\/span> certainly<\/span> no<\/span> evidence of success with operational integration<\/span>. <\/span>Most s<\/span>ervice providers <\/span>can <\/span>address both payer and provider <\/span>needs <\/span>independently <\/span>but have <\/span>yet to mak<\/span>e the transition to <\/span>integrated offerings to address vertical integration challenges, choosing instead to sell to legacy buyers.<\/span> It certainly does not help<\/span> that integrated healthcare enterprises continue to buy in silos, missing the benefits of integration.<\/span><\/span>\u00a0<\/span><\/span><\/span><\/span><\/p>\n

Employers will drive the next apolitical healthcare transformation<\/span><\/span>\u00a0<\/span><\/span><\/span>\u00a0<\/span><\/span><\/span>\u00a0<\/span><\/span><\/span><\/span><\/h3>\n

Employers are underwriting t<\/span>he health of ~30% of all lives in the US<\/span>,<\/span> increasingly seeking new models and channels to address the<\/span>ir employees’<\/span> shifting demographic<\/span>s<\/span> and needs globally.<\/span> Services providers <\/span>remain<\/span> on the sidelines of this marke<\/span>t, <\/span>unable to wrap their heads around this opportunity, assuming that s<\/span>ervicing ASO is servicing self-insured <\/span>employers<\/span>. The fastest and largest segment of the market is getting the cold shoulder<\/span> from most of the incumbent service providers<\/span>, allowing a new generation of service providers to take pole positions.<\/span><\/span>\u00a0<\/span><\/span><\/span><\/span><\/span><\/p>\n

Equity is <\/span>not <\/span>just <\/span>nice to have\u2026<\/span> it<\/span>\u2019s<\/span> an economic imperative<\/span><\/span>\u00a0<\/span><\/span><\/span>\u00a0<\/span><\/span><\/span>\u00a0<\/span><\/span><\/span>\u00a0<\/span><\/span><\/span><\/span><\/h3>\n

CMS added the Health Equity Index to Medicare Star ratings<\/span>, which<\/span> will be used in the 2027 rating calculations. So, the days of well-meaning health equity narrative<\/span>s<\/span> must now translate into action on the ground.<\/span> Consequently, service provider solutions for d<\/span>ata aggregation and analytics to address equity are <\/span>gaining <\/span>some traction, but solutions to drive sustainable and stronger impact have not seen much daylight<\/span> yet<\/span>.<\/span><\/span>\u00a0<\/span><\/span><\/span><\/span><\/span><\/span><\/p>\n

The Bottom Line: Although t<\/span>he <\/span>buy<\/span>–<\/span>side <\/span>market dynamics <\/span>have<\/span> shifted significantly<\/span>, <\/span>the sell-side <\/span>remains<\/span> biased toward<\/span> the legacy.<\/span><\/span><\/span><\/span><\/span><\/span><\/strong><\/span><\/h3>\n

Payers<\/span> have morphed into service providers themselves and <\/span>are stumbling about to craft <\/span>a viable<\/span> future path. So, service providers <\/span>that <\/span>have gained success by answering the mail and plainly addressing the needs of payers <\/span>should <\/span>rethink their success levers in the future. The game has changed, and so will the way it is going to be played.<\/span><\/span>\u00a0<\/span><\/span><\/span><\/p>\n

HFS subscribers can download the report here<\/span><\/a>.<\/span><\/h3>\n","protected":false},"excerpt":{"rendered":"

Global coverage for healthcare continues to shift away from commercial underwriting to governments as the quadruple aim of care (cost…<\/p>\n","protected":false},"author":3,"featured_media":5986,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[876,64,975],"tags":[1324,384,1352,1165,1166,1351,619,1350,1103],"organization":[],"ppma_author":[913,923,19],"class_list":["post-5985","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-healthcare","category-healthcare-and-outsourcing","category-hfs-horizons","tag-fersht","tag-healthcare","tag-healthcare-enterprises","tag-healthcare-industry","tag-healthcare-providers","tag-healthcare-transformation","tag-phil-fersht","tag-quadruple-aim-of-care","tag-rohan-kulkarni"],"yoast_head":"\nThe decline of commercial payers is an opportunity to address new markets - Horses for Sources | No Boundaries<\/title>\n<meta name=\"robots\" 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