Finding success as a Payer is more difficult than ever before. Regulatory compliance, competition, internal processes, and ever-increasing customer and member expectations are placing significant pressure on Payer organizations.
This increasingly complex landscape means that many Payers have been forced to find new solutions and partners who can help ensure they meet their fiduciary obligations under the law.
The burden of care for Payers is that they must act with skill, prudence, and diligence under the circumstances. In the past, when accurate data and benchmarking was not available, this burden was more easily met. However, pushes for transparency in healthcare have created a proliferation of data that is now available for sponsors to use when designing their health plans and making decisions with respect to plan assets.
Growing access to this data means that the level of sophistication required to fulfill the duty of prudence under the Employee Retirement Income Security Act (ERISA) puts some sponsors in a position where they need to employ new resources to use the data available to them.
Ignorance of Data is No Excuse
As legal and regulatory pressures increase, Payers who serve as plan fiduciaries face ever-changing activity requirements to meet their legal and ethical responsibilities. More than ever, Payers need to be transparent in their decision-making and ensure that they leverage accurate data when selecting provider networks, other health solutions partners, or making general decisions about spending plan assets.
While the amount of data available is increasing rapidly, many Payers do not have the infrastructure or internal resources required to make use of it effectively. This situation results in an environment where Payers are required to act on information they simply do not have the tools to analyze or use successfully.
To use this data effectively and continue to fulfill the fiduciary responsibilities to their plan members, many Payers have begun working with third-party solutions that have the resources capable of handling large and complex arrays of data.
Payers Need New Strategies to Avoid Benefit Erosion and Inflated Premiums
When a health plan provider is not making informed decisions, they are at risk of being in breach of their fiduciary duties. Wasting assets or overpaying for care leads to benefit erosion, inflated premiums, and inadequate healthcare resources for plan members. To fulfil their obligations, Payers need a way to accurately compare prices and identify the best Health Market Partners for their member population.
Choosing best-fit provider networks and other Health Market Partners is one of the most important ways that Payers can control spend while providing exceptional care to their member populations. However, selecting the optimal network is not always easy. Diverse member populations mean that identifying a best-fit network requires holistic analysis.
As more health market data becomes available for Payers to use, the process of identifying the best Health Market Partner can be a matter of leveraging the right solution. Partnering with a firm that leverages technology optimized to make decisions and take action based on this data enables Payers to automate time-consuming aspects of this process.
How Benchmarking Solutions Can Help
Plan sponsors now have access to extensive pricing data. While the raw data may be difficult to decipher and compare, benchmarking solutions help frame the information within the larger healthcare landscape. More extensive price shopping is likely to become part of the fiduciary requirements for Payers, but performing these price comparisons is only one part of identifying best-fit solutions.
Once a Payer has identified the optimal partners for their member or employer groups, they still need to take steps to connect to each partner. To simplify this process, Payers should explore solutions that help them create actionable plans based on the data they have available. A platform that can identify the highest quality care at the lowest cost for members, while ensuring the Payer meets their fiduciary responsibilities, is invaluable in the current healthcare landscape.
MacroHealth’s Intelligent Health Markets Set Payers up for Success
Healthcare data will transform the way Payers identify Health Market Partners- they now need access to tools designed to use the information effectively. While developing a new data solution can take time and resources that many Payers cannot spare, platforms like MacroHealth’s Intelligent Exchange (MiX) can help.
The MiX platform is an innovative Intelligent Health Market as a Service (IHMaaS) solution that leverages the power of data and a marketplace approach so you can better meet compliance requirements and gain a competitive advantage.
With easy access to internal and external market data, coupled with industry-standard interoperability, payers can streamline operations, enhance transparency, and foster collaboration among stakeholders to transform healthcare access, reduce care and administration costs, and ultimately enhance the quality of care.
If you want to learn more about how the MiX platform works, and how it can help Payers maintain their fiduciary responsibilities, watch our demo video.