A post-reform environment in the U.S. has changed payer business models across nearly every line of health insurance product offered, and established new business opportunities in terms of payers looking to acquire health IT solutions for not only the purpose of internal use, but also to sell applications to other payers. One example of this trend that will continue is illustrated by Fallon Community Health Plan in Massachusetts, which licenses back office applications supporting dual eligible lines of business to Inova Health System in Virginia. Many of the payers I have worked with in the last few months tell me they are actively looking for new solutions from entrepreneurial companies to address many of their "pain points" for which existing solutions are not a good fit. These payers represent both medium to large size organizations including national and regional lines of business. In many cases, such as with the larger, national payers, there is an existing business division that is charged with seeking out and evaluating new IT solutions and companies. Offering non-insurance lines of business such as IT applications and related services is quickly becoming part of the changing payer business model.
Some of the payer "pain points" include the following areas:
1) Clinical and financial analytics that operate in a secure, SaaS and/or cloud environment, are highly scalable, can access and analyze structured and unstructured clinical data, and enable a high degree of user customization in terms of data field, report levels, and user ID access. These analytic applications also need to interface with a payer's core claims system to enable the customization and administration of value-based reimbursement models, most of which are still being defined in terms of pay for performance (P4P), global or bundled payments, and other shared risk arrangements such as Accountable Care Organizations (ACOs).
2) Consumer navigation and engagement tools providing real-time, meaningful decision support capabilities in a public or private exchange environment AND support consumer healthcare decisions AFTER enrollment. This area must be mobile enabled and provide more of a retail experience than traditional payer mobile apps.
3) Meaningful price transparency tools that educate consumers on meaningful concepts of price and value while supporting care decisions - this is a particular challenge as the industry struggles to define the concept of "value in healthcare" in a way can identify with.
4) Meaningful quality and cost reports to providers that are pushed out (versus requiring a logon to yet another payer portal) with timely, actionable information that drives improvements over time.
On April 24, 2015 I will be participating in a panel discussion in Washington, D.C. focusing on what providers and payers are buying and how - see the attached flyer and http://www.nelsonmullins.com/register/HealthTechInnovators2015 for more information.
In addition, AHIP recently announced the AHIP Innovations Lab an “action hub” where payer organizations can immerse themselves in all aspects of a particular IT challenge and work side by side with IT solutions partners. Check out this article for more information!
Questions, comments? Contact me at firstname.lastname@example.org.