Typically, payer organizations collect premiums from employers and individuals, process claims, and engage in a variety of case management/disease management activities to encourage the appropriate use of medical resources. If they collect more premiums than claims paid, their medical loss ratio is less than 100% and they earn a profit.
In a world of accountable care organizations and healthcare reform, new reimbursement methods will include global payments to providers, which implies the risk of loss will shift from the payer to hospitals and clinicians. Payers will no longer need their large claims processing staff, nor create complex actuarial models. They’ll become very different organizations.
My prediction is that payers will become the health information exchange and analytics organizations that help hospitals and clinicians manage risk in a world of capitation.
I’ve said before that ACO=HIE+Analytics.
The payers are already making strategic acquisitions to build these new business models
United acquired Axolotol to gain expertise in healthcare information . United already had a comprehensive suite of analytic capabilities via its Ingenix subsidiary. United rebranded the combination of HIE plus analytics as OptumInsight.
Three of the nation’s largest Blue Cross plans acquired Navinet for its real-time communication network that links physicians, hospitals, and health insurers.
Humana acquired AnvitaHealth for its real time analytics and decision support capabilities.
The next several years will be interesting to watch as the country gains experience from Pioneer ACOs (7 of the 32 are in New England and 5 in Massachusetts).
Watch the payers carefully. As they acquire more HIE and Analytics businesses, I believe you’ll see a shift from claims processing to wellness management and cloud-based provider services.
John D. Halamka, MD, MS, is Chief Information Officer of Beth Israel Deaconess Medical Center, Chief Information Officer at Harvard Medical School, Chairman of the New England Healthcare Exchange Network (NEHEN), Co-Chair of the HIT Standards Committee, a full Professor at Harvard Medical School, and a practicing Emergency Physician. He’s also the author of the popular Life as a Healthcare CIO blog.