Detroit, Miami, Phoenix and New York are among the markets with the most space for collaborations called “payvider” to grow, a new report found.
The consultancy Guidehouse studied more than 100 populations of the American markets, enrollment in insurance and cost and quality metrics to compile their report, which is intended to help providers and insurers in each area decide to partner. or to go alone. Increasingly, payers and suppliers are increasing their returns collaborating on risk-based collaborations, Either in the form of partnerships or formal joint ventures with transfers of assets.
The industry is at a turning point in terms of how payers and providers are encouraged to keep patients healthy, said Dr. Nicole Fetter, director of Guidehouse.
“Payers need providers to perform on quality, costs and access more than ever to earn full revenue potential,” he said, “and providers need payers and buyers while insuring patients and caregivers. members that providers serve ”.
Guidehouse found the metropolitan areas around Detroit, Miami, Phoenix, Tampa and New York have the highest current Medicare benefits and managed Medicaid penetration combined with projected enrollment growth. They also demonstrated scope for improving cost and utilization metrics such as Medicare per capita costs, Medicare Advantage star ratings, and emergency department utilization.
Other meters in this category include Charlotte, NC, Orlando, Cincinnati and Cleveland. The Cleveland assessment, for example, suggests that there is a great opportunity to increase value in terms of costs and quality, the report said. There are also demographic changes that will happen that will fuel the growth in Medicare and Medicaid managed care memberships.
Fetter acknowledged that markets in each of the report’s categories are very different from each other, and said that’s why a variety of components come into play. For example, Miami scores little value because its Medicare per capita costs are so high. In Detroit, by contrast, there is poor access to primary care and higher age-appropriate mortality.
The Guidehouse report, the inaugural focus for the Payvider Health Insights Market Index, included only meters with populations over 500,000 based on market size and future growth. He lists the meters by population size, and Fetter noted that the larger the population, the greater the opportunity for membership growth.
The report also included Los Angeles, San Francisco, Riverside, Calif., Minneapolis and Albuquerque, NM, and said these markets already have many payers and suppliers accompanied by high cost and quality performance. Guidehouse said payers and suppliers could further differentiate existing delivery and payment options based on value.
In Albuquerque, there are many high-performance players and expected member growth, the report says.
Another group that includes Seattle, Denver, San Jose, Calif., Salt Lake City and Des Moines, Iowa has membership growth potential based on relatively low value given demographic and payer changes, but existing players are scoring well. on cost and quality. In the case of Des Moines, for example, Medicare Advantage’s potential and Medicaid’s managed growth is low, so players in that market may want to think about expanding their footprint elsewhere, Guidehouse said.
A fourth group that includes Chicago, Dallas, Houston and Washington, DC has low growth potential and has not performed well in terms of cost and quality. In the case of Dallas, Medicare Advantage is already high with significant competition. The real opportunity exists for the provider community to differentiate their cost management capabilities and population health, Guidehouse said.
The payvider trend is driven in part by the increased importance of Medicare and Medicaid in health insurance companies, particularly Medicare Advantage. The largest and most obvious example of a payer is UnitedHealth Group’s Optum Care subsidiary, which has more than 53,000 doctors and 1,450 clinics across the country.
Another example is the value-based care joint venture formed in 2016 between Phoenix-based Banner Health and Aetna that were last expanded with a long-term agreement in February 2021. Banner and Aetna said they have seen savings from average costs between 8% and 14%, better member experience and growth to about 350,000 members.
In the Detroit area, Henry Ford Health System formed a network of clinically integrated physicians in 2007 that brought together its medical team and independent providers to increase quality and efficiency. It is now one of the highest performing Next Generation ACOs in the country and has a direct partnership with the owner with General Motors.