2024 Payer Outlook: Opportunities and Considerations
Executive Summary:
In anticipation of the year 2024, the healthcare payer sector faces a complex landscape marked by rising costs, technological advancements, regulatory changes, and evolving patient needs. Key considerations for payer executives include managing higher costs, leveraging artificial intelligence (AI), especially generative AI, for optimizing operations, maintaining government business resilience amidst regulatory shifts, addressing pharmacy value-chain complexities, and reevaluating the administrative-services-only segment.
Main Considerations:
1. Managing Higher Costs:
- Therapy Utilization: Effective but costly therapies like GLP-1s for diabetes and obesity, and precision oncology treatments contribute to increased utilization.
- Health System Labor Shortages: Persisting shortages impact costs, potentially leading to a 9% increase in employer insurance rates if a $100 billion health system cost increase is factored in.
- Cost Pass-Through: Employees may face increased medical service expenses, with some paying over 75% of discretionary income.
2. Leveraging AI for Optimization:
- Process Enhancement: Opportunities exist to optimize administrative and medical processes using AI, including generative AI, automation, and digital technology.
- Favorable Implications: Rapid adoption of AI could reduce costs across all payers, affecting health system management, benefit contracts, and more sophisticated proposal responses.
3. Government Business Resilience:
- Regulatory Changes Impact: Recent Medicare, Medicaid, and Individual market changes strain payer businesses.
- Competition Shift: The basis of competition may evolve from price to benefits, distribution, and retention, potentially leading to established players displacing disruptors.
4. Pharmacy Value-Chain Complexity:
- Member Experience: Prescription drug purchases are challenging due to limited choice and high out-of-pocket costs.
- Innovation Needed: Payers might explore alternative payment models, such as outcome-based or site-neutral payments, to manage costs effectively.
5. Reenergizing the Administrative-Services-Only Segment:
- Profitability Variability: ASO profitability ranges widely, with opportunities for greater pricing innovation and tailored product packages.
- Vendor Strategy: A shift towards building partnerships at scale based on shared risk, platform agility, and seamless integration could improve outcomes.
6. Unproven Business Models and Scale Partnerships:
- Vertical Integration Challenges: Investments in pharmacies, providers, and alternative care sites have yielded mixed results.
- Payer-Agnostic Assets: Access to new profit pools may be possible without achieving expected cost benefits.
- Point Solutions: Collectively, these can lead to administrative burdens and degraded consumer experiences, suggesting a need for a comprehensive vendor strategy.
Conclusion:
Payer executives must navigate these challenges while capitalizing on emerging opportunities, particularly in AI-driven optimization, resilient government business strategies, pharmacy innovation, and restructured administrative services. Strategic partnerships and a focus on outcome-based solutions are key to sustaining and growing in the dynamic healthcare landscape of 2024.
医疗保健实践
2024年付款人前景：机会比比皆是
付款人高管在2024年应对潜在挑战并为未来增长定位时需要考虑的五个因素。
作者：Monisha Machado - Pereira
2022年,我们关于医疗保健风暴的文章1专注于付款人部门面临的不确定性。虽然大部分隐喻风暴已经过去，但其后果不应该是
重新确定使那些提供了稳定的付款人利润和增长来源的企业(医疗保险、医疗补助和个人)变得紧张。
低估了。展望2024年，我们为付款人高管提供了五个主要考虑因素。
If Medicare Advantage provides an analogue for the evolutionof the Personal segment, the basis of competition may shiftfrom price toward benefits, distribution, and retention. Themore established players may therefore displace displainters,given given the depl
更高的成本-以及生成AI的承诺
付款人注意到，由于有效但昂贵的治疗方法，如广泛的人群药物（例如，用于2型糖尿病和肥胖症的GLP - 1s，以及用于非酒精性脂肪肝疾病的治疗）和高成本
对于Medicare Advatage和Maaged Medicaid，必须坚持不懈地执行既定的价值杠杆。Dals（符合Medicare和Medicaid资格的成员）的收购和管理将是MedicareAdvatage的关键战场。对于Medicaid，我们对提案请求的分析表明，通过基于风险的安排和合资企业与提供商建立更紧密的整合可能具有竞争力。
输注药物（例如，精密肿瘤学）。
卫生系统的劳动力短缺仍然有增无减，并且不太可能在2024年缓解。我们估计，卫生系统成本的增加1000亿美元可能会转化为9％的雇主保险费率增加。转移给员工的成本可能会导致最脆弱的成员为医疗服务支付超过75％的可支配收入。
制药价值链复杂性驱动创新
对于许多会员来说，购买处方药是一种复杂而令人沮丧的经历。处方药的自付费用将超过$500 billion in 2023, more than what members pay forhospital care. Despite the benefit structure对于高度易购的产品,选择受到难以转移的处方、网络设计和部分价格可见性的限制。在许多情况下,消费者的药物分摊费用超过计划发起人支付的净价。某些药物的患者自付费用通常可以设定为25%或更多的标价，造成严重的遵守问题。
我们的分析表明，即使对于已经进行了行政转型的付款人，仍然有机会使用人工智能进一步优化流程，包括生成AI（gen AI），相邻自动化和数字技术。正如我的同事在本报告的早期部分所述，潜在的行政和医疗成本降低
纲要，展示了时代人工智能的快速采用如何对所有付款人产生有利的影响。这可以从卫生系统和福利合同整理和查询到更复杂的提案请求响应生成。然而，围绕数据隐私、治理和变更管理的挑战依然存在。对于许多付款人来说，最大的问题是从哪里开始以及如何开始。
付款人可以考虑与制造商和卫生系统更紧密地合作，以替代付款和融资模式（例如，基于结果或站点中立的付款）。2023年，成本管理方法的几个例子浮出水面：Elevance Health收购BioPlus进入专业药房服务，BlueCross Blue Shield创建了Synergie
尽管存在限制，但政府业务弹性
医疗保险费率、风险调整模型、星级标准和医疗补助的最新监管变化
药物承包组织，以及加州蓝盾公司决定解构药房福利经理价值链，并与合作伙伴合作，走向净价直接承包和其他模式一起与药品制造商。
提供者和替代护理场所。但是，通过计划成员更全面地使用和整合所获得的资产，可以实现投资价值的增加。这仍然难以捉摸。例如，根据麦肯锡的分析，目前尝试整合的大多数老牌付款人只有不到20％的成员使用其拥有的提供商资产。在这种情况下，付款人不可知的性质。
的资产可以提供访问新的利润池，但没有更综合的模式的预期成本收益。
重振仅行政服务部门
仅行政服务（ASO）的盈利能力范围从负5％到正20％的EBITDA。2对于一个由500到2,000名员工组成的团队，我们估计领先的国家和地区参与者之间的平均ASO收入收益率差异约为每位员工每月80至120美元。这种差异表明了更大的定价创新，针对特定客户群的全面和分层的产品包装以及相应的竞争性报告和销售队伍有效性的机会。
对于大多数付款人来说，材料并购交易的成本过高。这导致了“点解决方案”的激增。这些可能是单独看是有效的，但总的来说，它们可能是行政负担，可能会降低消费者体验。付款人可以考虑对其供应商战略进行全面修订，以便基于成果的共同风险、平台敏捷性以及努力成为无缝解决方案集成商来大规模建立合作伙伴关系。那些加速并大规模维持解决方案的人不仅可以在短期内取得成功，还可以为未来的增长奠定基础。
未经证实的商业模式为大规模合作铺平了道路付款人一直在尝试通过对药店的投资进行纵向整合，
莫尼沙·马查多-佩雷拉是麦肯锡湾区办事处的高级合伙人，并领导麦肯锡与北美医疗保健付款人的合作。
