Payers in the Health Care Industry
In this article, we’ll discuss who health care payers are, the challenges they face, and what they are doing to streamline and coordinate care across all providers in the health care industry.
What Are Payers?
Payers are usually not the same as providers. Providers are usually the ones offering the services, like hospitals or clinics. However, there are some instances where a payer and provider are the same entity. An example of this is Veterans Affairs, where patients can receive care at the facility while having care covered by the facility (or being referred to other specialists).
Examples of Payers
Currently, the top five payers in the market are:
- UnitedHealth Group (49.5 million members)
- Anthem (40.2 million members)
- Aetna (merged with CVS; 22.2 million members)
- Cigna (15.9 million members)
- Humana (14 million members)
These top payers are part of private insurance plans while payers like Medicaid and Medicare are part of the public sector.
What Challenges Do Payers Face?
- Uncertainty over health care reform
- IT/systems integration
- Aligning incentives with health care providers
- Consumer education/understanding of coverage and costs
- Consumer education/self-responsibility for health
- Rise in patient pay responsibility/high deductible health plans
- Providers entering the payer space
- Providers consolidating
- Fewer medical professionals for case management
- Rise in employer self-insurance
All of these issues present unique problems for payers and, ultimately, the rest of the health care industry.
How to Move Forward
Develop Care Management Systems
- Promoting lifestyle programs for healthier living, weight loss, and quitting smoking
- Identifying gaps in care for preventative screenings, follow-up appointments, or prescription refills
- Implementing intensive care for patients with serious health issues
Activities like this help to promote cohesive care across all facilities.
Effective Care Management Systems
- Data integration
- Flexible workflows
- Patient advocacy
- Cultural competence
- Leadership support
As payers implement these efforts to make care coordination more effective, it will help lower health care costs over time and create a better care experience for everyone.