What is a payer/insurer?
Typically, payer organizations collect premiums from employers and individuals, process claims, and engage in a variety of case management/disease management activities to encourage the appropriate use of medical resources. If they collect more premiums than claims paid, their medical loss ratio is less than 100% and they earn a profit.
In a world of accountable care organizations and health care reform, new reimbursement methods will include global payments to providers, which implies the risk of loss will shift from the payer to hospitals and clinicians. Payers will no longer need their large claims processing staff, nor create complex actuarial models. They’ll become very different organizations.
My prediction is that payers will become the health information exchange and analytics organizations that help hospitals and clinicians manage risk in a world of capitation.
I’ve said before that ACO=HIE+Analytics.
The payers are already making strategic acquisitions to build these new business models
Aetna acquired Medicity to gain expertise in health care information exchange. Aetna had already acquired Active Health to gain access to its CareEngine analytics platform.
United acquired Axolotol to gain expertise in health care information . United already had a comprehensive suite of analytic capabilities via its Ingenix subsidiary. United rebranded the combination of HIE plus analytics as OptumInsight
Three of the nation’s largest Blue Cross plans acquired Navinet for its real-time communication network that links physicians, hospitals, and health insurers.
Humana acquired AnvitaHealth for its real time analytics and decision support capabilities.
The next several years will be interesting to watch as the country gains experience from Pioneer ACOs (7 of the 32 are in New England and 5 in Massachusetts).
Watch the payers carefully. As they acquire more HIE and Analytics businesses, I believe you’ll see a shift from claims processing to wellness management and cloud-based provider services.
In addition to his CIO role at BIDMC, Dr. Halamka blogs at GeekDoctor.blogspot.com.