Healthcare Payers Pivot As Pandemic Changes Member Behavior - Bain & Company
Healthcare Payers Pivot As Pandemic Changes Member Behavior - Bain & Company
Healthcare Payers Pivot As Pandemic Changes Member Behavior - Bain & Company
Brief
At a Glance
This article is part of Bain's report US Healthcare Trends 2020: Insights from
the Front Line. Explore more insights from the report here.
their members, considering both cost and convenience. They are rethinking
provider reimbursement to motivate a greater shift to lower-cost care settings.
And payers are seeking to defend their roles as care managers through
investments in innovative care management tools and, for some, primary care
ventures. We explore each of these trends below.
Prior to the pandemic, most patients using telehealth were willing to “see any
doctor.” That allowed the payer (and its telehealth partner) to enable that care.
During the pandemic, however, providers accelerated their move into
telehealth, allowing patients to “see my doctor” for ongoing care and creating
new engagement models between physicians and patients that deepened
those relationships. For example, some primary care physicians began offering
telehealth appointments during off hours and weekends, filling a role often
played by urgent care clinics today. Many consumers prefer this “see my
doctor” approach, calling into question payers’ prepandemic strategy.
Cost-related cases are those that allow payers to reduce costs through
telehealth, mainly by adjusting incentives to shift in-person care to digital
visits. These include episodes of care where telehealth can successfully replace
an emergency department visit (e.g., diverting Level 1 or Level 2 acuity care to
telehealth), where a follow-up appointment can be conducted digitally, or
where specialized services such as mental health assistance or difficult-to-
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A payer’s decision on the right mix of cost vs. convenience and members’
desire to “see a doctor” vs. “see my doctor” will help determine whether the
company should buy or build telehealth services, or partner with an existing
telehealth vendor. Payers that want to offer “see my doctor” telehealth options
to members may consider partnering with local medical groups. Those that
prefer to offer “see a doctor” are likely to build a platform or partner with a
scale telehealth vendor.
Forward-looking payers are reacting to these shifts in three ways. They are
adjusting reimbursement policies to further encourage use of lower-cost care
settings. One example is site-neutral reimbursements (both fee-for-service and
bundled). Payers are also seeking to shift reimbursement to value-based care.
Historically, providers have been reticent to move to value-based care given
profit pool compression. That may persist for many health systems, but our
research found that 39% of primary care physicians are more willing than ever
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Expanded business models. To win in the postcrisis era, leading payers are
making investments, building partnerships and exploring acquisitions that
will further expand their business models. Two areas, in particular, stand out:
innovative approaches and platforms for care management and increased
participation in primary care.
To compete with third parties and preserve their historic care management
role, leading payers are starting to play more active roles managing member
relationships and make investments or acquisitions to reclaim these
touchpoints. These investments could be a blend of navigation tools, disease-
specific care management plays and digital engagement platforms.
Historically, primary care has been a fork in the road for payers: Some have
invested heavily, while others have insisted they are staying away. But Covid-
19 has changed the primary care market dynamics, forcing some payers to
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reconsider. First, continued cost pressure is convincing some payers that they
need to control the front door of care. At the same time, increased financial
pressure on primary care providers has made acquisitions attractive in some
markets. Our research shows that 69% of physicians in independent primary
care groups would consider acquisition, up from 29% in 2019
TAGS
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