Masterclass: Overview of Providers, Payers, and Patients

Posted By The Academy

July 6, 2023

Update your knowledge of the healthcare landscape with this review of the latest data and trends on three key stakeholders in healthcare: providers, payers, and patients.

Takeaways on Providers

1. Physician networks, which can be comprised of both independent and employed physicians, are essential for referrals, care coordination, and collaboration. While health systems typically employ physicians to have greater influence over referrals and coordination, employment doesn’t guarantee loyalty and independent physicians can be tightly aligned to health systems as well. It’s critical to understand how physicians are affiliated with a health system because it can impact decision-making and involvement in strategic and operational initiatives.

2. Increasingly, LHS rely on a broad team of non-physician clinicians to succeed on the goals of population health and overall cost of care reduction. LHS aim to deploy nurses, APPs, and a broad variety of other clinicians at the top of their license to provide care. However, LHS face a host of workforce challenges such as critical shortages and concerns over clinician wellbeing. Understand that workforce shortages may be a serious limit to LHS growth. When considering new investments, LHS may require significant demonstration of ROI that directly alleviates workforce challenges and reduces labor cost growth. They may have a very low tolerance for technology that imposes “extra clicks” or burdensome implementation processes. Ensure your products and solutions lessen, not add to, the clinician's burden.

3. Patients can be treated in inpatient, outpatient, or home/virtual care sites. Where care is provided is influenced by a variety of factors beyond acuity and need, such as physician referral, patient preference, and payer policy. Overall, outpatient volumes are growing while inpatient volumes are declining. This ongoing shift was accelerated by the pandemic, which also promoted a shift to virtual and home care models, like Hospital at Home. Assess the portion of your products and services that are tied to strictly inpatient use and consider if you need to develop new services or products that are purpose-built for the outpatient, virtual, or home care environment. Consider how to potentially reframe your value proposition to support goals in outpatient, virtual, or home care.

Takeaways on Payers

4. The majority of Americans have commercial insurance and commercial payers make up the majority of hospital patient care revenue. However, patients over 65+ and with certain disabilities are eligible for Medicare, and enrollment has been rising steadily. Patients not eligible for Medicare and who do not get insurance from employers can purchase it on public exchanges, or if they meet requirements, can get Medicaid insurance. Each LHS, and market has a different payer mix. Understand how external factors can affect payer mix and impact LHS margins.

5. Enrollment in Medicare Advantage, an alternative to traditional Medicare whereby payers and even providers can take on the risk for the cost of care of insured lives, is increasing and replacing traditional Medicare. LHS leadership are increasingly interested in leveraging MA to get closer to a premium dollar and secure higher reimbursement rates than traditional Medicare. LHS need accurate data to enable informed decision-making and manage the total cost of care and outcomes for MA patients they take on. Understand where health systems are in MA adoption and if they own a plan. If they are participating in MA, find ways to assist with various challenges, such as the need for accurate timely data. Evaluate if and how products and services could enable LHS success in MA initiatives.

6. Lower reimbursement rates from public payers exert pressure on providers’ margins and require cross-subsidization from private payer patient reimbursement. LHS may therefore strive to negotiate even higher rates from private payers which increases payer costs and may raise premiums and deductibles for private patients. Understand how increased public patient volumes and utilization rates can impact the cost of healthcare for private patients and the burden on healthcare systems.

Takeaways on Patients

7. Overall, the US population is getting older and sicker. Patients aged 55 and up account for over half of health expenditures and 21% of the population will be 65 or older by 2030. As a result, patients may need more complex care. At the same time, LHS will have a larger part of their revenue tied to public payers like Medicare and Medicaid--putting pressure on their margins. Make sure your value proposition includes a strong clear financial ROI as LHS grapples with these financial pressures.

8. Traditionally, patients are unlike any other industry’s customers– as payers and providers can have a lot of control over their options. Access can be limited, and prices are often not transparent. However, with increased out-of-pocket costs and a bevy of consumer-oriented options, patients are becoming more empowered and choosier. As patients act more like true consumers, they evaluate attributes such as convenience, price of care, personalization of care, and accessibility. Evaluate how your products/services empower customers to make choices in their care or if they can health systems’ ability to attract consumer-oriented patients.

9. Health systems are beginning to embrace consumerism and are pushing digital health and associated tools to retain current customers and engage new ones. A digital strategy will play a key role in meeting patient expectations, improving accessibility, easing scheduling, and connecting the entire patient experience. Evaluate how your products/services improve digital connectivity. Consider marketing how products and services can align directly with health system digital strategy to retain patient loyalty and keep them connected to the system in an ongoing manner.

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