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Payer Transformation Trend:
Medicare Advantage Enrollment Skyrockets

Trend

What It Means

Payers have an immediate business case to succeed within the MA value-based, star ratings framework.

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Infrastructure needed for MA success is then available for self-insured commercial purchasers who are slowly but increasingly demanding similar payer accountability.

Medicare Advantage (MA) becomes the biggest money maker for BUCAH companies.

 

BUCAH, Blue Cross Blue Shield, UnitedHealthcare, Cigna, Aetna, Humana.

For a payer to attain high-quality ratings, a certain level of alignment and collaboration with providers is necessary.

In Medicare Advantage and increasingly in commercial markets, payer success requires high-quality affordable care delivered to members/employees.

Payers have less leverage relative to:

  • Rate negotiations

  • Facility fees

  • Demanding providers use high-value care pathways and reduce the incidence of low-value services, which are often big revenue generators for hospitals (eg, inappropriate stents in cardio “cash” labs, non-necessary imaging and labs, etc)

Meanwhile:
Provider organizations have spent the past decade consolidating to wield unprecedented market power in certain regions. They also have bought up independent primary care provider practices as part of their consolidation strategy.

It is clear that controlling primary care is a way for health systems to maximize high-profit in-network health system referrals.

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