提供者主导的健康计划如何在商业保险中取得成功（英）

plans can succeed incommercial insurance Provider-led health plans are underrepresented in the commercial groupinsurance market, leaving more than $20 billion in potential revenue and$700 million in operating margin on the table. byAneesh KrishnawithAditya Gupta,Muhammed Ziauddin, andNikhil Mahajan Commercial insuranceis a critical element in the US healthcare ecosystem. It represents thelargest segment of healthcare financing, covering more than 165 million individuals in 2024, orabout 62 percent of the total insured population.1National carriers are the leaders, with half themarket by enrollment. Health systems that have developed insurance capabilities, known asprovider-led health plans (PLHPs), lag behind at 10 percent. PLHPs have the potential to improve care coordination and affordability for members throughcloser alignment between care delivery and coverage. They have a big opportunity to increasetheir presence in the commercial market, the most financially attractive segment for payers.According to McKinsey analysis, they could capture more than $20 billion in additional revenue,equivalent to roughly 30 percent of PLHPs’ current total revenue pool, more than $700 million inoperating margin, and 5.5 million more members if they aggressively pursue the opportunity.2 In this article, we look at the challenges facing PLHPs in the commercial market, why this marketis attractive, and how they could expand into the market by pursuing product innovation,optimizing pricing, and sharpening go-to-market tactics. Why provider-led health plans have struggled in the commercial market The commercial market structure favors large, established national carriers due to operationalscale and administrative efficiency. National carriers lead with a 50 percent share of thecommercial enrollment, followed by regional Blue Cross Blue Shield plans at 35 percent andPLHPs at 10 percent (Exhibit 1). PLHPs’ operating margins lag behind industry averages. Most had operating margins of less than2 percent in 2024, trailing national carriers and larger regional Blue Cross Blue Shield plans. Thelatter two achieved operating margins ranging from 3 to 8 percent (Exhibit 2). What has held provider-led health plans back PLHPs have struggled to increase their share of the commercial market. Structural limitations andcapability gaps have prevented them from achieving the scale and competitiveness of nationalcarriers (see sidebar, “Forces reshaping commercial markets for provider-led health plans”). The commercial market features low customer turnover and intense competition. Only 15 to 20percent of employer groups actively seek new plans annually.3Such switching behavior favorslarge national carriers with broad provider networks and established broker relationships.Companies that have employees in multiple locations usually prefer carriers that can providecoverage across multiple locations and have existing ties with insurance brokers or consultants. Exhibit1 Some of the challenges facing PLHPs in the commercial market include the following: —PLHPs’ limited geographic reach restricts their competitive scale. —Many PLHPs lack the operational infrastructure and expertise required to scale effectively.Outdated claims platforms, limited pricing sophistication, and insufficient actuarialcapabilities can hinder their ability to compete with more advanced national and regionalplayers. —Misalignment between the health system and health plan sides of PLHPs createsinefficiencies.4For example, when the PLHP is unable to drive stronger care coordinationwithin its own health system than that of an external payer, it can erode the PLHP’s valueproposition. Similarly, the inability to establish centers of excellence (CoEs) that providehigh-quality care with specialized providers may further undermine its value proposition. Exhibit2 —PLHPs trail their national and regional competitors in product innovation. Their competitorscontinually introduce differentiated offerings to capture additional market share and sustainhealthy operating margins. These challenges have collectively stalled PLHPs’ ability to scale, leaving many of them unableto compete effectively with the national and regional carriers that lead commercial insurance.Addressing these barriers will require a fundamental shift in strategy, investment, and execution. Forces reshaping commercial markets for provider-led health plans Two major developmentsare reshaping the commercial insurance landscape, presenting both risksand opportunities for provider-led health plans (PLHPs). Coverage shifts from Medicaid or individual to employer-sponsored plans Recent policy changes, such as a planned reduction in Medicaid funding and removal of enhancedsubsidies for the Affordable Care Act (ACA) under the One Big Beautiful Bill Act, are expected topush 11 million lives out of Medicaid and ACA plans by 20341and potentially encourage people toobtain coverage through employer-sponsored mark