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Healthcare Payer Industry Trends

Healthcare is an essential, dynamic, and opportunity-rich industry. The demand for technological innovation to drive inclusive improvement in outcomes, affordability, quality, and access will continue to be high. The payer spent on IT sector is growing at the CAGR of 7% every year. Recent government regulations around interoperability and changes brought in through CMS Interoperability mandates, PPACA and Medicare/Medicaid expansion have resulted in a shift in focus towards digital transformation, which has set the industry on a fast-paced evolution path. Embracing a true digital transformation across the value chain is now intrinsic to progress. The end goal is an enterprise delivering seamless experience to its stakeholders despite the challenges and we are here to help you in this journey towards a transformed future aligning with the following industry trends.

Industry realignment: Horizontal and Vertical Integration has undoubtedly become an aggressive approach to business expansion in the healthcare industry. Healthcare industry is going through significant consolidation with PBMs buying Payers and Payers acquiring Providers, a well-thought-out merger or acquisition can lead to an assured path to success. One strategic move can result in the elimination of direct competition while boosting efficiencies, level of production and economies of scale. With large healthcare players such as CVS, United Health Group and Anthem investing more on acquisitions and models such as ‘Pay-viders’, the entire health ecosystem is undergoing a business model transformation and benefitting from this change.

Value based contracts (VBC): Value based care, population health management and risk sharing arrangement have been a promising way to shift the payer’s focus from volume to value, and achieve the triple aim of improved population health, lower costs, and improved patient experience. While closing care gaps, improving HEDIS measures, and improvements on metrics such as completed annual wellness visits, reduced ER visits, and inpatient admissions are mechanisms payers use to get into value-based contracts with providers, the increased engagement with members digitally to offer a continuous care paradigm focusing on holistic approaches such as nutrition, mental/behavioral health, fitness etc. will pave the way for continued success in value-based contracts.

Pandemic Disruption: The year 2020 gave rise to numerous innovations and changes in the ‘new normal’. Value based contracts, telehealth with audio and video consulting and mobile health with fitness and wellness applications are some of the best example to validate the ecosystem of digital transformation. Technologies such as Artificial Intelligence, Machine Learning, Blockchain and Automation are being leveraged in the industry for predictive care, diagnosis, remote healthcare delivery tracking health records now more than ever.

Consumerism: While every other industry has consumers at the center of any business model change or transformation, in healthcare “patient-centricity” is still an afterthought. Meeting consumer expectations has become the top imperative now in Healthcare, and to stay ahead of the curve healthcare players are evolving from a “sick care” industry to a “consumer driven” one. It has facilitated members to achieve a sense of confidence in making their own healthcare decisions. Factors such as emergence of mHealth apps and wearables, evolution of public and private insurance exchanges and proposition of websites offering transparency into price and quality have led to evolution of passive patients to empowered consumers.

Interoperability and Connected Health: The focus on interoperability and transparency is increasing to enable the health information shared across all stakeholders at the right time to ensure the highest quality of care to the patients/members. According to research reports, the industry is expected to grow by 3 billion by 2021 with 13% CAGR on account of Interoperability and HER Integration. Government decrees transparency in information sharing through Interoperability guidelines while regulating privacy and health information protection through HIPAA privacy mandates. Organizations are adapting blockchain technology to meet their needs effectively without any compromise and add significant value to the connected health ecosystem.

Technology driven Operational Improvement: With growing technological innovations accelerating growth in every industry, it is crucial for healthcare payers to turbocharge their IT initiatives and shape strategy around digital transformation for business growth. Improvement in business operations across claims administration, plan and benefit management, sales and broker operations, membership enrolment and eligibility, provider network and contract management etc. will continue to be achieved through investments in digital transformation initiative across cloud, automation, data management and analytics, workflow management etc.

Medicare and Medicaid driven Expansion: While the percentage of people covered under Medicaid/Medicare continue to grow, the percentage of older people covered under Medicaid will grow faster over next decade, which will result in higher number of Dual-eligibles and overall higher spend on these programs. Traditionally, this segment is not as engaged with health plans as the commercial segment, their expectations will continue to evolve and the payers will have to bring all the bells-and-whistles to serve this segment, which they are already building for their commercial membership. We also observe the advent of new players serving this high-risk, complex population, such as Landmark, Concerto health, CityBlock health, driving new consumer-centric care delivery models and providing a uniform experience across clinic and home. These players are heavily backed by private equity and leverage the power of Digital technologies to enable integrated and continuous care and are expanding the size of population they serve by expanding their alliances with MCOs.
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