Payer Transformation Trend: Payers Buying Providers
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)
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.
APCs such as Iora Health, Oak Street, City Block, and others have demonstrated their ability to deliver high-value care and keep patients out of hospitals and emergency rooms.
Virtual-first providers create far better consumer experiences than traditional provider organizations. Dynamic plan designs reduce cost sharing for consumers who use digital-first offerings. Together, this generates cost savings by steering consumers to low-cost specialty providers, labs, and imaging.
When payers are in charge, employed providers become less incented by volume and relative value unit generation and more incented to provide high-value care and reduce downstream spend.
Payers respond in 3 ways:
Employing their own providers or joint ventures to share risk
Offering “virtual first” and hybrid “care at home” plan designs and service offerings in tight collaboration with virtual providers across the country
Leaning into relationships with “advanced primary care” (APC) practices that truly deliver population health
Payers have immense amounts of data (both claims and electronic health records). They are using these data in various ways:
Identifying patients with care gaps
Identifying patients with “rising risk”
Conducting quality analytics on providers, ranking them for total cost of care and for following best-practice care pathways
Using data to steer patients within narrow networks (up to a point if you’re a BUCAH with legacy network contracting restrictions … in a big way if you’re a third-party administrator like Centivo, etc)
Implications of payers employing some providers and deepening their relationships with others, including virtual care providers: DATA are generated
Pharma needs to:
Have products on formulary
Align with value-based care
Consider value-based contracts