Tag: healthcare payers

Healthcare Payers Enjoy Rising Revenues, but COVID Is Still Taking a Bite Out of the Bottom Line | Press Release

COVID-19 continues to shape Healthcare Payer financials, business strategies and IT investment trends

If profit margins were a theme park attraction, Healthcare Payers would have experienced quite the roller-coaster ride in the last 18 months, according to Everest Group.

Payer margins spiked in Q2 of 2020—rising from 2.6% to 6.8%—as a result of COVID-19 induced deferment of non-emergent procedures. Then, in the second half of 2020, operating and net income dropped to 2.5% as healthcare utilization rebounded. In Q1 2021, healthcare payers reported substantial profits (4.1%) as higher enrollment in government plans drove strong revenue growth, especially for Medicare Advantage (MA) plans, though commercial enrollment was still below pre-pandemic levels. In Q2 2021, despite posting strong revenue growth, payers experienced a drop in operating and net income, with net profit margin falling to 3.2%, due to an increase in COVID-19 care costs for testing, treatment and vaccination. Some payers also cited acquisition costs to explain the drop in income.

These findings are examined in more detail in Everest Group’s recently published State of the Market Report, “Healthcare Payer Enterprise Insights – H1 2021.” In this report, Everest Group examines payer performance in H1 2021, focusing on industry- and account-level financial and Line of Business performance as well as key business and IT investment themes. Payers profiled in the report include Anthem, Centene Corporation, Cigna, CVS Aetna, Health Care Service Corporation (HCSC), Highmark, Humana, Kaiser Permanente, Molina Healthcare and UnitedHealthcare.

COVID-19 Continues to Shape Healthcare Payer Trends
COVID-19 has fundamentally altered the functioning of the healthcare industry by significantly changing who receives care and how they access it.

Evolution of Healthcare Payer Business Strategies

  • In 2020, healthcare payers began looking beyond the immediate issues of cost takeout and capacity utilization toward improving access to care through home care and telehealth capabilities. Payers sought to increase operational efficiency and enhancing member engagement through improved outcomes, increased productivity and lower costs for members.
  • In H1 2021, home care, telehealth and integrated, coordinated and preventative care emerged as key themes. Payers leveraged partnerships and acquisitions to enhance their capabilities and improve member experience. In addition, payers are expanding their Medicare Advantage business by offering virtual and digital health capabilities. Payers also report the launch of various initiatives to tackle vaccine hesitancy and expand vaccination coverage.

Shifting IT Strategies

  • In 2020, the COVID-19 pandemic accelerated the need to future-proof technology, and healthcare payers responded by investing significantly to modernize legacy systems and leverage artificial intelligence (AI), machine learning (ML) and robotic process automation (RPA) technologies to reduce operational inefficiencies and automate time-consuming processes.
  • In H1 2021, healthcare payers continued the modernization quest. More specifically, payers are modernizing legacy platforms by shifting to integrated, cloud-based platforms and cloud-native applications. The payer industry is leveraging blockchain-based public ledger technology to improve transparency and interoperability in healthcare.

***Download a complimentary abstract of the report here.***

About Everest Group
Everest Group is a research firm focused on strategic IT, business services, engineering services, and sourcing. Our clients include leading global companies, service providers, and investors. Clients use our services to guide their journeys to achieve heightened operational and financial performance, accelerated value delivery, and high-impact business outcomes. Details and in-depth content are available at http://www.everestgrp.com

Break-ups are Painful, Difficult, and Costly; The Current Insurance Payer Merger Saga | Sherpas in Blue Shirts

In July 2015, two mammoth players in the U.S. health insurance market decided it was time to form even bigger entities, similar in size to UnitedHealth Group (which held 17 percent of the market.) First it was Aetna deciding to merge with Humana, primarily consolidating the Medicare Advantage market. A few days later, Anthem and Cigna, with a relatively more complementary membership base, decided to merge.

By the end of 2015, shareholders of all four insurers had approved the deals. However, the Department of Justice and several states (mostly Democratic ones) opposed and appealed against the mergers. In early February 2017, the federal court ruled both anti-competitive and blocked them, citing increased concentration.

Had the mergers been approved, Anthem-Cigna would have led the market with highest share of the entire insured population, followed by UnitedHealth and Aetna-Humana. In Medicare Advantage (MA), Aetna-Humana would have surpassed UnitedHealth to become the market leader.

Insurance payer mergers

Let’s take a look at what transpired in both cases.

Aetna and Humana
On February 14, 2017, the two companies mutually decided to end the merger agreement, rather than appeal the antitrust decision. Due to a contractual clause intended to ensure both parties remained encouraged by the merger prospect, Aetna will have to pay Humana a break-up fee to the tune of US$1 billion. This massive financial hit does not include various other expenses Aetna had to incur in order to prepare for the deal, including legal and accounting fees, bonds issuance fees, interest to be paid while repurchasing the bonds, and the premium it has decided to pay for bond repurchases. All told, the total cost of the merger that didn’t happen will be around US$2 billion for Aetna. This is a relatively straightforward scenario, albeit very costly for Aetna.

Cigna and Anthem
This is a much more complicated situation. Since the merger was first announced, a lot of animosity has grown between these two insurers. Cigna has gradually changed its stance from being pro-merger to anti-merger. In fact, Cigna has gone to the length of filing a lawsuit against Anthem, and asking for $13 billion in damages. This does not include $1.85 billion that Anthem owes to Cigna as a termination fee. Anthem, however, appealed this, claiming that the merger deal timeline is valid until April 30 – and it is still hopeful for merger activity.

Unless Anthem and Cigna accept the ruling without appeal and carry on with business as usual, I see two possible scenarios here:

  • Convince the new administration that the deal will have a positive impact on consumers, and get it approved with the help of the new head of the Justice Department
  • Accept the ruling, and use the money (planned or already raised) to fund acquisitions of smaller payers without triggering the antitrust regulations

The first option seems less likely. However, since the new U.S. president’s swearing in ceremony, we have seen that extreme events cannot be explicitly ruled out with the new administration. Additionally, Trump’s and Republicans’ plans to repeal and replace Obamacare will require support from the industry…and who better to support this than two of the top three publically-listed payers? Another key element in favor of these mergers being approved is that the new administration is more lenient when it comes to antitrust matters than the previous administration, as evidenced by the possible approval of the Bayer and Monsanto deal.

The second option would result in Anthem paying a hefty amount for failure to be able to complete the deal.

The high termination fees for these deals gone bad will likely negatively impact Aetna and Anthem (if indeed the Anthem/Cigna merger doesn’t happen.) For example, per the latest filings, Aetna’s net margin has declined from ~5.9 percent in 2011 to 3.6 percent in 2016, while Anthem’s was 2.9 percent in 2016, down from ~4.4 percent in 2011. As a result of the lawsuit filed by Cigna, Anthem will end up shelling out even more than Aetna, as even if we the decision is in favor of Anthem, it will still have to pay litigation expenses.

Insurance payer mergersThe road ahead for these payers is filled with uncertainty, especially for Anthem and Cigna, since they are embroiled in a legal battle. Yet one thing we can be certain of is that Aetna and Humana are watching from sidelines, potentially resuming merger talks if the Anthem-Cigna deal is approved. While it remains to be seen how the new administration reacts, things should get clearer in the coming months.

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