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Payers in the Health Care Industry

There are many facets and branches to the health care industry, making it difficult to receive entire-body care from one facility or provider. This is where coordinated care across the care continuum comes into play. But, who is responsible for coordinated care? Health care payers.

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.

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What Are Payers?

Payers in the health care industry are organizations — such as health plan providers, Medicare, and Medicaid — that set service rates, collect payments, process claims, and pay provider claims.

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

With more than 900 health insurance companies operating throughout the United States, there are many payers in play throughout the industry. These companies offer 67.3% of private health care and 34.4% of public health care, respectively, through their health plans.

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?

There are many challenges facing the health care industry and payers have their own share of the difficulties. While rising health care costs are the ultimate issue for patients, providers, and payers alike, payers deal with other issues, including:

  • 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

Payers are seen as change leaders in health care and have the responsibility to make effective changes to health plans and overall care services. Payers are seamlessly coordinating care across the care continuum to create a better health care experience for everyone.

Develop Care Management Systems

Care management systems and strategies aim to address chronic problems, prevent diseases, and promote patient wellness as a whole. Payers can focus on developing and implementing activities such as:

  • 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

To make care coordination more effective, payers need to create care management systems that have certain requirements, including:

  • 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.