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How Healthcare Payors Can Cut Overspending

January 24, 2018 BY Alanna Moriarty

How Healthcare Payors Can Cut Overspending

*Updated June 2019

The federal government continues to make healthcare funding a point of focus. For instance, in 2018, it used the Children’s Health Insurance Program (CHIP) as a bargaining tool to end a three-day government shutdown. After a lapse in long-term funding that lasted 114 days—nearly four months—Congress finally approved legislation that would fund CHIP until 2024. In emphasizing the refunding of CHIP, lawmakers have seemingly forgotten about community health centers—for which funding also ran out on Sept. 30, 2017.

This constant debate over healthcare funding, as well as the disputes surrounding the Affordable Care Act (ACA) and Medicaid expansion, have both patients and healthcare providers bracing for increased premiums and out-of-pocket payments. According to the CDC, by March 2018, 28 million Americans (8.8 percent) did not have health insurance. This upward trend is particularly damaging for rural patients and providers, with nearly double the number of rural facility executives than urban executives reporting that higher deductibles would negatively affect their practices.

Top Payers by Total Direct Premium Earned

Payer Name Premium Earned (M) Covered Lives
Kaiser Permanente Group $46,362 8,979,348
Anthem BlueCross & BlueShield $42,612 7,332,153
UnitedHealthcare $40,581 8,745,902
Health Care Service Corporation Group $26,939 4,556,722
Aetna $19,942 3,574,735

Fig 1 Data from Definitive Healthcare's Payer platform, June 2019

For the first time, more than half of Americans are faced with insurance deductibles of $1,000 or more. This could result in denial of care from providers, reluctance to seek care from patients, and an increase in charity care spending—all of which would negatively affect a healthcare payer’s bottom line. The good news is that payers can reduce spending waste and effectively manage costs in an uncertain market.

 What is a Healthcare Payer?

The term “payer” refers to Preferred Provider Organizations (PPOs), Health Maintenance Organizations (HMOs), healthcare service contractors, state insurance agencies, claim handlers, and more. The primary difference between a health plan and a payer is that a health plan pays the cost of medical care, and a payer is an entity responsible for the processing of patient eligibility, services, claims, enrollment, or payment. Healthcare payers account for approximately 80 percent of all healthcare spending in the United States.

There is some conflict regarding the use of “payer” versus “payor.” Though both spellings are used interchangeably, “payor” is the usage preferred by the American Medical Association (AMA), and the most widely searched on Google.

Top Payers by Covered Lives

Payer Name Covered Lives Premium Earned (M)
Kaiser Permanente Group 8,979,348 $46,362
UnitedHealthcare 8,745,902 $40,581
Anthem Blue Cross & Blue Shield 7,332,153 $42,612
Health Care Service Corporation Group 4,556,722 $26,939
Aetna 3,574,735 $19,942

Fig 2 Data from Definitive Healthcare's Payer platform, June 2019


All-Payer Claims Databases

All-Payer Claims Databases (APCDs) are extensive electronic systems that methodically collect healthcare claims data from payers. Currently, 19 states have an APCD in place and 5 states are undergoing the implementation process. To develop an APCD system, state governments must assess the local healthcare market. This includes an evaluation of the health insurance market and public payers, development of data submission guidelines, and the validation and management of patient health data.

Though it seems like an immense amount of work and can be costly to maintain, the payoff is significant in terms of population health monitoring as well as in the reduction of unnecessary healthcare spending. Because APCDs are statewide systems, data sharing between payers, providers, and regulators is simplified. This allows for easy analysis of medical claims and identification of areas where financial waste can be prevented. Wasteful spending costs employers up to $2 billion per year, or about one-fifth of the total spend, according to a 2017 report from the American Health Policy Institute (AHPI).

APCDs can educate payers and other stakeholders on areas where healthcare services are overutilized, or where preventative care could have positively impacted overall spending. Once payers have this data, they can work with providers to deliver more comprehensive care, improving care outcomes and reducing costs. For example, a research team reviewing APCD data in Virginia found that unnecessary low-cost healthcare services, like lab tests, EKGs, and vitamin D screenings, cost more than $586 million annually. Similarly, participants in CMS Health Care Innovation programs used APCD claims data to reduce care costs by around $600 per beneficiary per year.

Researchers at the West Health Policy Center (WHPC) estimate that nationwide adoption of APCD systems could save around $61 billion for the healthcare industry.

Top Payers Participating in an ACO

Payer Name Premium Earned (M) Covered Lives
Anthem Blue Cross & Blue Shield $42,581 7,332,153
UnitedHealthcare $40,581 8,745,902
Aetna $19,942 3,574,735
Florida Blue $13,565 2,253,142
Blue Shield of California $11,482 2,324,102

Fig 3 Data from Definitive Healthcare's Payer platform, June 2019

Blockchain

Patient out-of-pocket payments make up 35% of national healthcare spending. This increased investment means that patients will have higher expectations for care outcomes, provider communication, and data security. Like current EHR systems, blockchain eases communication between providers and payers, making data easily accessible to those who have permission to view it.

Blockchain is an expandable list of electronic records that are connected and secured using encrypting technology. Adoption of blockchain in healthcare has been slow to start but has vast potential as electronic health records (EHR) and electronic medical records (EMR) become virtually omnipresent. EHR systems and healthcare facilities can be vulnerable to cybersecurity breaches, as we’ve seen with Anthem BlueCross BlueShield, UC Davis Health, Bronx-Lebanon Hospital Center, and others. Implementing blockchain could save the healthcare industry around $68 billion per year by eliminating fraud.

Like APCDs, blockchain compiles massive amounts of patient data, allowing for easier analysis. This could allow employers that offer health plans to see the categories of care that are costing the most money—and implement wellness initiatives to combat it. Rather than using wearable technology that monitors individual employee activity levels, blockchain could offer a window into the reasons patients seek care, whether it’s smoking cessation, weight loss, or other areas.

Blockchain is still in its infancy, so it’s unlikely that it will be implemented on a large scale this year. However, companies like Change Healthcare have already introduced their own versions of blockchain for hospitals and payers, so widespread implementation could be closer than originally thought.

Learn More

If you’re only looking at publicly-facing CMS claims data to research, target and sell to the healthcare provider market, you’re not seeing the full picture. More than half of the country has private insurance and, currently, there are limited ways to access this private claims data.

In most cases, private claims information exists in the form of flat data files that are difficult to search through, sort, manipulate, correlate, and compare against other sets of data. To solve this market need, Definitive Healthcare amassed billions of private (commercial) claims and seamlessly integrated them into its easy-to-use platform. This platform features a search tool that enables its users to find relevant medical and Rx claims data, as well as the unique ability to view CMS and commercial claims data in aggregate. By combining billions of private medical and Rx claims with CMS and proprietary data, Definitive Healthcare empowers its users to better analyze healthcare market trends, develop comprehensive segmentation strategies, identify industry leaders, and hone sales and marketing strategies.

Definitive Healthcare tracks:

  • 1 billion Medical Claims annually for 7,900 hospitals and nearly 1.3M healthcare professionals
  • 900 million Rx Claims annually, bringing clarity to the prescribing habits of more than 1 million physicians across the U.S.
  • 247 million covered lives total (from 2016 to the present)
  • 150 million covered lives annually 

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