2. Payers will always have to balance competing priorities: access and sustainability

Like providers, payers perform a balancing act between offering broad access to the greatest number of people and trying to sustain the system.

Ideally, they want to steer patients toward providers they know and trust. This helps keep costs down by limiting the most expensive care, for example readmissions for chronic disease. Patients, however, generally want freedom to choose providers they like; and so a tug of war ensues.

We have never seen payers hold so much power as they do now, especially with large health systems beginning to offer their own health plans and Medicare Advantage plans.

Under normal circumstances, the system works for healthy people. They can get routine and emergency care — and pay for it — under one roof; however, this also leads to fewer choices and less competition, which historically only drives up costs over time.  

3. Payers will always try to get closer to the point of care

As we just laid out, the greatest example of this is when health systems have their own health plans. 

But there can be other more nuanced ways for payers to influence the point — and cost — of care. Short of full-scale vertical integration, payers have the potential to engage in their own care management efforts to help improve patient outcomes and reduce risk.

This kind of engagement — going beyond the transactional nature of insurance — has been happening for decades, but it has never consistently worked to improve patient experience, quality of care and/or lower total costs because it ignores the one constant since the beginning of health care: patients trust their providers. 

For any care management strategy to be successful, it must be implemented as an extension of the provider, not the payer.

4. Private payers will follow CMS 

How closely and in what ways vary, but private payers and the Centers for Medicare and Medicaid Services are locked in an eternal dance. At a foundational level, private payer rates are based on a percentage of the Medicare rate. Therefore, when Medicare adjusts, the entire industry pays attention. 

They don’t always match steps, but the kind of commanding power CMS has over private payers through this singular mechanism likely won’t change, as we see in this 2017 article about CMS’ understated influence on private payers. 

5. Fees and networks will continue to frustrate patients

This is a result of the fragmented health system we’ve discussed in the other two parts of this series (see What Won’t Change? Part One: Patient Experience and What Won’t Change? Part Two: Provider Experience). Narrow networks will continue to separate patients from their providers of choice. 

A new interim rule from the Department of Health and Human Services gives patients a little more confidence when seeking care that may or may not be in-network, especially in the emergency department and operating room where several providers with inconsistent network affiliations deliver care to the same person.

Payers don’t have agreements with all providers, which inevitably means some doctors will always be out of reach for some patients. 

What do we take from the persistent parts of payer experience? 

The desire to control costs links together all of the payer experience mainstays. 

As a chronic care management company, Signallamp Health understands how routine maintenance for the sickest patient segments drives down expenditures while making care more sustainable and accessible for a greater number of people.

Of people in poor health, the top 90th percentile accounts for 100 times the annual spending compared to people in the 10th percentile, according to the Brookings Institution report we mentioned at the top. That’s the difference between $700 and $70,000 annually.