Payer Transformation Trend:
Medicare Advantage Enrollment Skyrockets
What It Means
Payers have an immediate business case to succeed within the MA value-based, star ratings framework.
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:
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)