May 11, 2023Unlocking New Opportunities for Innovation in Healthcare

In today’s healthcare market, payers are challenged with accelerating, unsustainable healthcare costs, evolving regulatory requirements, and increasing internal pressures as these challenges become amplified by disruptive technology and market forces. Healthcare payers must become more agile and adaptable to stay competitive. However, with restrictive budgets, limited internal resources, and a finite timeline to innovate, they cannot build the type of solutions needed to accomplish these goals themselves.

As a result, the provider data management space is fragmented and supported by legacy technologies. These solutions are typically comprised of tools and capabilities that deliver directory generation and data mapping, all of which are often integrated into a larger set of capabilities for provider network management. However, due to the No Surprises Act, Price Transparency1 and other regulatory pressures around interoperability and patient access, the industry has seen an increase of intelligent data solutions, as well as platforms that enter this space to improve data integrity and management.

According to the most recent Gartner® Market Guide for U.S. Healthcare Payers’ Provider Network Management Applications, “Many vendors’ provider network management (PNM) point solutions follow payers’ decision-making silos, hindering PNM efficiency and efficacy. Payers are seeking holistic, end-to-end replacements or integrations with customer relationship management (CRM) tools for provider data, workflow and relationship management.”2

So, how do you move forward?

In the Gartner® Market Guide for U.S. Healthcare Payers’ Provider Network Management Applications, analysts suggest that payers:
“Improve the total experience by replacing legacy PDM tools and point solutions with solutions that have modern architectures that allow for real- and near-real-time insight. Focus on vendors with strong solution roadmaps and a commitment to real- time data interactions, interoperability and automation to support fast-evolving provider relationships.”2

Additionally, according to the Gartner® Market Guide for U.S. Healthcare Payers’ Provider Data Management Applications: “Price transparency regulations and increasing value-based care initiatives and contracting are making provider network optimization an essential PNM capability for payers.”3

Steer away from tried and traditional approaches

To innovate and grow their organization, payers must look beyond the two most common approaches that they have relied on in the past:

The first approach is the status quo among payers – doing their own data analysis. The problem here is that healthcare data isn’t interoperable. It’s opaque, inefficient, and disconnected, all of which prohibit payers from identifying opportunities for growth within their ecosystems.

The second traditional approach is building your own vendor stack. Health plans, employers, and government entities often run exhaustive and expensive RFP processes and string together singular point solutions in hopes of finding optimal, cost-effective solutions. However, this approach addresses pain points individually, and as those point solutions multiply, it becomes challenging – or even impossible – to keep up.

Find cost savings and fuel innovation with MacroHealth

The MacroHealth Intelligent Exchange platform gives you the holistic, end-to-end solution you need to address spiraling healthcare costs and other high-influence factors, allowing for true innovation.

The MacroHealth Intelligent Exchange (MiX) platform provides payers with a composable digital health architecture, allowing payers to partner with best-of-breed vendors and create their own connected ecosystem specific to their populations. With our platform, payers can adapt to the ever-changing landscape of healthcare without needing to rearchitect their internal Core Administrative platforms.

The platform does this in a three-step process: Optimize, Connect, and Innovate.

During Optimize, you can identify your optimal provider networks and health solutions partners for your member population. Ultimately, finding the solution that will reduce costs without eroding member benefits.

Next, during the Connect component of the platform, you can integrate with your preferred networks and partners after you’ve created your solutions.

And finally, it’s during the Innovate step that the MiX platform enables you to fuel innovation and growth. The platform delivers unique innovation by constantly monitoring opportunities to drive down your total cost of care using real-time data combined with predictive and prescriptive analytics. As data passes through our platform, it is automatically normalized, so that the data received from your external partners can be combined with your internal data, providing you with a big picture perspective. Additionally, our machine learning, advanced analytic algorithms are continually looking for patterns and trends that will help you further optimize your healthcare spend.

The MiX platform provides a window into opportunities that have been out of reach until now – facilitating new revenue models, expanded offerings to health plan members, and collaboration with other market players, opening the door to new revenue channels.

We are committed to providing transformational healthcare technology and empowering payers with a holistic view of real-time data, intelligence, and transparent pricing information, unlocking an optimal total customer experience and better bottom-line benefits.

Ready to unlock new opportunities? Reach out to a MacroHealth representative to learn how we can support you.

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  1. CMS, Transparency in Coverage Final Rule Fact Sheet(CMS-9915-F)
  2. Gartner, Market Guide for U.S. Healthcare Payers’ Provider Network Management Applications, February 2023
  3. Gartner, Market Guide for U.S. Healthcare Payers’ Provider Data Management Applications, February 2023

GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved. Gartner does not endorse any vendor, product or service depicted in its research publications, and does not advise technology users to select only those vendors with the highest ratings or other designation. Gartner research publications consist of the opinions of Gartner’s research organization and should not be construed as statements of fact. Gartner disclaims all warranties, expressed or implied, with respect to this research, including any warranties of merchantability or fitness for a particular purpose.

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