Top Areas of Change Required of US Health Payers

Deanne Kasim

Guest post by Deanne Kasim, IDC research director, payer health IT.

Part of the role of being a research director is to analyze current industry trends, developments and policies and help clients navigate these IT, market, economic and regulatory changes. A post-health reform environment has accelerated the rate of change in all these areas. I recently developed a discussion of the top 10 areas of change payers need to focus on for the next 12 to 18 months (http://www.idc.com/getdoc.jsp?containerId=HI253579). The following is a brief discussion of the top three predictions.

Payers need to develop greater understanding of who their consumers are and adopt more of an omni-channel approach for reaching and meaningfully engaging different population segments.

Consumers understand how to assess the concept of value in other areas of their lives, such as researching information to purchase a new car, a major appliance, or a house. But they do not have nearly as good of an understanding on the way health insurance works, how to necessarily use it, or how to define value in insurance benefits and care choices. Health reform has forever changed the business model of health insurance and placed consumers front and center in the equation. This increased emphasis on the consumer needed to happen a long time ago and now payers are challenged to radically change how they develop, market, and administer health insurance benefits accordingly. IT tools and applications are quickly evolving to better support the consumer’s purchase decisions and use of insurance benefits, and payers are continuing to realize the potential and importance of this developing product area.

According to IDC Health Insights’ 2014 Payer Survey, payers were split between increasing the 2014 budget for consumer engagement strategies (49 percent) and keeping the budget the same (51 percent). I fully anticipate these numbers will be higher in this year’s survey, as more payers commit additional resources to the development and support of thoughtful consumer engagement strategies, processes and IT applications.

As the industry moves from pay-for-volume to pay-for-value payers need to form more “win-win” relationships with providers and this requires leadership, trust and the IT applications and analytics to support this.  

The longtime practice of paying for volume is changing rapidly to pay for value, and the U.S. Centers for Medicare & Medicaid Services (CMS) continues to lead developments in pay for value methods, including a variety of value-based reimbursement (VBR) practices, pay-for-performance (P4P) and global or episodic payments. The establishment of patient centered medical home (PCMH) and accountable care organization (ACO) models, combined with the reduced reimbursement realities under the ACA, has incentivized more providers and payers to explore new, mutually beneficial reimbursement arrangements. Providers and payers will have an increasing need for analytics applications to help predict and monitor clinical quality outcomes and financial performance measures in order to make VBR arrangements work for all involved stakeholders. In addition, as payers continue to employ narrow networks as part of their public HIX business line strategy, VBR arrangements with the contracted providers can enhance the performance of both payers and participating providers. 

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