Today’s Top Five Healthcare Payer Financial Opportunities

在我的金融职业生涯中，我有机会在医疗保健支付人和提供者组织工作。Now I work with a company that partners with many types of healthcare organizations to tackledataand promote improvement. In this article, I use my finance experience to identify five key areas of opportunity for finance improvement in the payer sector and provide a framework for payer CFOs to build new business models that prioritize growth, strategic recommendations, and performance management.

New Business Models Must Address Cost, Access, and Quality

We operate in an environment with many stakeholders. And while each can describe the issues, no one has developed quick, easy solutions—leaving healthcare’s outlook into the 2020s unclear. Existing business models have created growth for many sectors in our industry, with healthcare now making up18 percentof the U.S. gross domestic product (GDP). As the threat of healthcare consuming our economy grows, we need a new model to address the problems of cost, access, and quality.

The new model accommodates the needs of all stakeholders (as all stakeholders should have a share of therisk), keeps the patient/member at its center, and prioritizes simplicity and alignment. Perhaps, the best new model example we have is theMedicare Advantageprogram; it keeps the members the focal point and shares risk with payers and providers under a government program.

目前，大多数美国人通过私人健康保险获得医疗保险。大小雇主提供全保险的团体计划或自筹资金的团体计划。根据美国人口普查局2017年的数据，私人医疗保险覆盖了67%的人口，而政府计划只覆盖了约38%的人口。Of the approximately 1,200 health insurance companies in the United States, Forbes lists thetop fivelargest payers for 2018 based on U.S. membership:

• UnitedHealth Group (49.5 million members).
• Anthem (40.2 million members).
• Aetna (merged with CVS; 22.2 million members).
• Cigna (15.9 million members).
• Humana (14 million members).

These large payers feel the urgency to lower cost and improve access and quality. UnitedHealthcare demonstrated this resolve in their market and mission in their fourth quarter 2018news release—a powerful statement showing commitment to cost and quality:

“UnitedHealthcare provides global health care benefits, serving individuals and employers, and Medicare and Medicaid beneficiaries. UnitedHealthcare is dedicated to improving the value health care consumers receive by reducing the total cost of care, enhancing the quality of care received, improving health and wellness and simplifying the health care experience.”

Five Healthcare Payer Opportunities for Financial Improvement

Five current opportunities for financial improvement can help payers respond to demands for new models for today’s healthcare environment:

1. Understand the Impact of the Affordable Care Act

2014年，《平价医疗法案》(ACA)在每个州建立了市场交易，引发了行业挑战。然而，2019年，新法规的调整期已经结束，许多美国最大的医疗保险公司由于亏损而离开了个人市场。然而，那些调整了保费的保险公司现在在个人市场上盈利，在医疗补助和医疗保险市场上的整体收入有所增加。Medicare Advantage andMedicaid Managed Careplans continue to grow as government payers try to control spending.

The following examples show profit for some insurers under the new regulations:

• 经济顾问委员会于2018年3月发布了一份关于健康保险公司盈利能力的文件。它指出，所有的健康保险公司都有望在未来一年获得更多的利润。
• TheNational Association of Insurance Commissioners(NAIC) published first half 2018 financial data showing aggregate financial results are steady with a profit margin of 3 percent. A couple of notable trends showed changes from June 2017 compared to June 2018:
  • 在过去的五年里，入学人数每年增加了2%，总体入学人数增加了13%。
  • 每个成员每月(PMPM)保费增加了4.7%，索赔PMPM增加了2.6%。
  • Administrative expenses jumped 31 percent in the time period.
• A U.S.Government Accountability Office(GAO)报告指出，2016年，三家最大的发行公司在37个州累计持有80%以上的市场份额。这表明一个行业的集中度很高。Medicare Advantage的注册显示，前三大保险公司占据了55%的市场份额。这些保险公司是UnitedHealthcare(25%)、Humana(17%)和Blue Cross/Blue Shield(13%)。
• 我们看到了更多跨不同业务线的合并和收购，重点是为会员提供服务和降低成本。最近的是CVS和安泰，合并了一家连锁药店和美国第三大医疗保险公司。In aWall Street Journal文章中，CVS首席执行官拉里·梅洛表示，合并后的公司将专注于降低医疗成本，提高消费者对处方方案的坚持程度，扩大其会员基础，并通过其实体店提供更多服务。

Payer CFOs can stay in sync with the current state of healthcare finance by asking questions on three key categories:

• Growth: What is a potential area of growth in your market by segment? Who are the competitors? (Each geographic market has different characteristics, but we know our population is aging, so the Medicare Advantage market should be strong. CMS projected enrollment in Medicare Advantage to increase 11.5 percent for 2019.)
• Strategy: What healthcare companies would help us reduce costs or offer services our members value? (In general, insurers have chosen their plan offerings, and the state market has made decisions for the exchanges.) Now the pivotal question is, who are my best partners in providing value?
• Performance:如何减少行政开支?我们是否应该考虑零基础支出，并重新考虑任何支出领域?(The increase in administrative expense invites CFOs to address some specific issues for cross providers and payers and remove waste from the system.)

2. Be Ready for Potential Shifts Due to Regulatory Impacts

The fate of the ACA is part of our political landscape. We have heard calls to repeal and replace the ACA on one side and Medicare for All on another. Both options could bring huge changes for the health insurance industry:

• In 2020, the government could reinstate the health insurance tax (HIT), leading to increased premiums. As I listened to quarter-end investor briefings, most companies were proceeding with business as usual and not reacting to this potential shift. Internally, CFOs are considering all options and gathering data needed to react.
• In April 2019, CMS announced the final rule for Medicare Advantage plans with a 2.5 percent pay increase for 2020. CMS also plans to change the amount of encounter data it uses for risk score calculations. Current scores are calculated using 25 percent encounter data, which CMS wants to increase to 50 percent. More complete and accurate encounter data could lower the risk scores and reduce overall payment. CMS is allowing more flexibility for plans to offer supplemental benefits to patients with chronic conditions.
• 大型保险公司创造了创新的模式，改善了会员的护理，并提供了收入来源。消费者发现医疗保险优势在质量、成本和医疗系统导航方面的价值。消费者知道他们的成本，可以与一个供应商合作。支付者可以提供处方药、牙科、视力和健身。“Medicare Advantage has rebranded ‘managed care’ to ‘care coordination,’” said consultantPaul Keckleyof The Keckley Report.
• In 2019, there were approximately 300 companies offering Medicare Advantage products. In some cases, providers are entering the space with assistance from insurers or by starting a new business venture. The Medicare Advantage model has provided the best value for many stakeholders.

Regarding, the current and future regulatory environment influences, the payer CFO can ask the following questions:

• Growth: Do we have options in the government world of Medicare Advantage or Medicaid? How can we partner with government initiatives to enhance our services?
• Strategy: What can we offer our Medicare Advantage members with chronic conditions? What is impact of new regulations on encounter data?
• Performance: Can we offer new insights into monitoring the risk scores of our populations as the methodology changes?

3. Understand How Social Determinants of Health Impact Member Health Status

健康的社会决定因素(SDoH)是财务团队的新领域，并有望带来一些令人兴奋的变化。SDoH数据位于索赔之外，包括影响总体健康状况的条件和环境(例如，获得食物、住房、交通、识字、家庭和社会网络，以及许多其他影响健康的非医疗部分)。

卫生保健需要收集更多关于对人口健康影响的数据，这就产生了围绕SDoH的大量活动。SDoH的试点工作存在于医疗补助管理护理计划中，医疗保险继续扩大慢性病护理的选择。Recently two large payers showcased their efforts with investments that will benefit the community’s health status:

• In January 2019,Kaiser Permanenteannounced initiatives totaling $200 million to tackle housing insecurity in Oakland, California. The proposals are part of a comprehensive strategy to improve health outcomes by improving economic, social, and environmental conditions.
• UnitedHealthCare投资4亿多美元，在18个州的80个社区帮助建造4500套保障性住房，并提供现场健康生活支持。

The challenge to collect SDoH data will expand roles in all care delivery areas, as care providers will survey populations, add notes to medical charts, ask questions to help find barriers to good health for each member. Most importantly, SDoH data needs to be accessible by clinicians, care managers, and social workers, and we need to connect members with community resources. In April 2019UnitedHealthcare and the American Medical Association(AMA) unveiled a plan to create nearly two dozen new ICD-10 codes related to SDoH. These codes would standardize the way healthcare collects SDoH and increase accessibility for clinicians.

CFOs can ask key questions about SDoH:

• Growth: Can the use of SDoH help us grow sectors of business?
• Strategy: In what areas should we invest to improve the outcome of our members and community? What are we currently doing with SDoH, and what are our future plans? Who are the best community partners to help with the focus areas we evaluate as important to our members?
• Performance: How will data be collected and used? How can we maintain focus on specific areas? What are the results from the interventions, and how do we measure them? How can we minimize gaps in care and improve health?

4. Focus on Provider Relations

支付者依靠提供者为其成员提供护理。In recent years, the industry has focused heavily onvalue-based care(VBC), as CMS has implemented programs for various providers (e.g., hospitals and physicians). Measures are used to monitor quality, and poor quality has an economic consequence. Measures include patient experience, readmission rates, mortality rates, and safety of care (e.g., rates for hospital-acquired conditions).

As a value proposition, VBC links quality of care with cost to provide improved outcomes for patients and health plan members. Importantly, this trend is forcing discussions between the payer and provider, as both parties work on improvement. Payers and providers have a common ground with emphasis on quality by reducing utilization, preventing illness, and avoiding complications. Payers have claims data that shows all the places a member has received care. Providers need this data is to view the total cost of care for the member. For example, without comprehensive health data, a physician group may not know their patient has visited different EDs and urgent care centers.

提供者和支付者需要一起工作来设计支付计划并实现这些模型。健康计划熟悉风险的概念，随着风险转移到提供者，提供者需要关于如何管理风险的教育。

Payers can ask these questions about how the move towards VBC impacts their relations with providers:

• Growth: Can we partner with providers to design products that will attract more members? Can we ease the administrative burden of billing while increasing satisfaction for members?
• Strategy:我们如何改善信息交换?我们的初级保健网络有多强大?网络中的缺口在哪里?
• Performance:我们如何监督和奖励我们的供应商?我们如何将激励措施统一起来?当前的护理管理计划执行情况(结果)如何?我们怎样才能将结果提高50%呢?What value-based payment programs have been successful?

5. Prepare for Future Trends—Big Challenges and Uncertainty

Moving forward, healthcare promises big challenges coupled with rising uncertainty:

• Healthcare needs to transform the way it addresses our population needs. The 2019 HBO program,One Nation Under Stress, describes how U.S. healthcare is not meeting the our country’s needs, as social determinants, such as zip codes, increasingly determine life expectancy.
• Medicare for All could shift the market and eliminate large sections of health insurance. This will depend on election in 2020 and could be the largest threat to provision and payment of healthcare.
• Radical proposals are emerging, as consumers take a larger role in their health and many disruptors (e.g., Google and Amazon) enter sections of the market. The overall market is shifting from inpatient hospital care towards increased outpatient and ambulatory care.
• Medicare Advantage shows many indicators of positive performance, enrollment growth, increased offerings, and extra benefits.MedPac希望服务费用(FFS)和医疗保险优势计划之间的支付平价，这一点已经实现了。由于这些程序表现良好，它们可能是新模型的关键。
• 保健计划将继续优先考虑发展基于价值的支付模式。
• When theArizona Republic在2019年4月覆盖了医疗保健，亚利桑那州尊严健康的首席执行官琳达·亨特描述了医疗保健的状态，并提出了关键问题:
  • The payers, the federal government, everybody is looking for value-based care—what is the right cost, the right place and the right time to care for people?
  • How do we focus less on illness and more on wellness?
• 亚马逊(Amazon)、摩根大通(JPMorgan Chase)和伯克希尔哈撒韦(Berkshire Hathaway)建立了合作伙伴关系，名为Haven，专注于技术和其他措施，以降低医疗成本。“The ballooning costs of healthcare act as a hungry tapeworm on the American economy,” said Warren Buffet, CEO of Berkshire Hathaway, in aJPMorgan Chasepress release. “We share the belief that putting our collective resources behind the country’s best talent can, in time, check the rise in health care costs while concurrently enhancing patient satisfaction and outcomes.”

CFOs can ask the following questions to formulate and model potential new options as healthcare faces challenges and uncertainty:

• Growth:我们如何吸引新会员?我们需要什么技术和投资?
• Strategy谁是我们最重要的合作伙伴?Have we completed aSWOT(优势、劣势、机会和威胁)分析可以为新产品提供方向?是什么促使消费者决定购买健康保险?
• Performance: What are the most important metrics to monitor?

Embracing Today’s Payer Financial Challenges: An Opportunity for Transformation

支付方首席财务官可以在本文中使用这些问题来回顾他们在市场上的总体战略，招募每个组织的多个领域来分析趋势和分享结果。首席财务官和他们的团队可以为他们在产品、新市场和举措影响方面的管理领导提供有价值的见解。通过关注未来五年的许多机会，支付方首席财务官可以降低医疗保健成本，提高质量，并增加获得医疗保健的机会。

Additional Reading

Would you like to learn more about this topic? Here are some articles we suggest:

1. Customer Journey Analytics: Cracking the Patient Engagement Challenge for Payers
2. Six Challenges to Becoming a Data-Driven Payer Organization