Health plans vary immensely in their size, scope, and strategic priorities. A baseline understanding of the health plan market requires a grasp on the following dynamics:
How plans make money: Premiums, quality bonuses, diversified assets
Common “types” of health plans: National, regional, provider-sponsored, community/local
Key lines of business: Medicare Advantage, Medicaid Managed Care, employer market, individual market
Executive priorities: Strategy and growth, utilization and costs
Increasingly health plan executives think of growth as a health plan via two primary avenues: line of business growth and asset diversification.
Plans are rapidly chasing member growth in their insurance lines of business with Medicare Advantage receiving outsized attention given profitability and growth trajectory.
Many health plans are expanding their offerings to include diversified health care service divisions.
To grow, health plans must excel against strong existing competitors and established, yet evolving, market dynamics.
Provider relations is an imprecise term used to describe the relationship between health plans and providers — most notably physicians.
Collaborative providers are essential to advancing health plan strategic goals such as value-based care, behavioral health integration, and efficient specialty referrals.
The path forward seems clear: successful plans will relentlessly focus on physician-led, data-driven provider enablement.
The function of a health plan is to enable and equip beneficiaries to access the best care possible, which often means access to transformative, innovative models or treatments.
Health plans must support pioneering approaches that strengthen the patient experience, improve patient outcomes, and reduce cost of care.
This requires health plans to closely monitor and evaluate innovation in the care delivery environment on a variety of vectors such as pharmacy, virtual-care, and behavioral health.
Member engagement is the process of building, nurturing, and managing relationships with members to drive behavior change.
To build and manage relationships, health plans must deliver a good experience — both live and digital.
Resulting behavior change enables health plans to increase revenues or manage medical spending.
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