Healthcare enterprises have made digital adoption the bedrock of their growth strategies to optimize processes, realize cost efficiencies, and enhance member experiences. They are leveraging digital healthcare services for value-based care and population health management, as well as to comply with changing regulations. To support enterprises on their digital transformation journeys, providers are ramping up their capabilities through vertical-specific partnerships and acquisitions, investments in Centers of Excellence (CoEs), and training, among other things. These efforts are, in turn, driving the need for research and market intelligence on demand and supply trends in healthcare payer digital services.
An assessment of 26 healthcare payer digital service providers on capability- and market success-related dimensions
Enterprise sourcing considerations, highlighting the strengths and limitations of each healthcare payer digital service provider
What is in this PEAK Matrix® Report:
In this report, we present an assessment of 26 healthcare ITS providers who are mapped on the Everest Group PEAK Matrix®, a composite index of distinct metrics related to a provider’s capability and market impact. We focus on payer digital healthcare services market size and growth, digital service themes for healthcare payers, provider assessments on several capability- and market success-related dimensions, and Everest Group’s independent remarks on the providers to help enterprises make the right sourcing decisions.
The PEAK Matrix® provides an objective, data-driven assessment of service and technology providers based on their overall capability and market impact across different global services markets, classifying them into three categories: Leaders, Major Contenders, and Aspirants.
Anil Vijayan, Partner at Everest Group, will join other industry experts to discuss how several new trends, such as intelligent automation, digitalization, and telehealth have emerged as fundamental driving forces to sustain and transform the healthcare industry.
The speakers will explore:
Challenges and emerging trends in the healthcare sector
Adoption of intelligent automation in the healthcare industry
Critical capabilities of IDP solutions and their benefits for enterprises
How the healthcare sector is exploiting IDP to address some of the challenges faced by the industry
Health systems are increasingly seeking competitive proposals post-pandemic to outsource Revenue Cycle Management (RCM) and get the best prices and innovation in contracts. Learn what enterprises want and how providers can win these RFPs.
Why has outsourcing gained traction in the Revenue Cycle Management (RCM) market?
The hospital revenue cycle process was not immune to the many changes COVID-19 brought to the US healthcare provider ecosystem, causing health systems to significantly shift operations to survive.
Challenges such as financial pressure, regulatory changes, the quality care and patient experience focus, and digital penetration pushed health systems – who traditionally prefer to keep operations in-house – to look outside for support. This drove more than 10% year-over-year growth in sourcing in the RCM market in 2021, and the strong contracting activity continues to gain traction this year.
Several health systems, including MarinHealth, Baptist Health, SSM Health, and Bassett Healthcare, have entered into outsourcing agreements with third-party vendors. However, unlike most past arrangements when sole-source was the dominant sourcing model, RFP-led sourcing is now the preferred model for healthcare providers in the post-pandemic world.
Exhibit 1: Split of new Revenue Cycle Management (RCM) services deals in 2021 – sole-sourced versus RFP-led
Source: Everest Group’s coverage of 32 major RCM services outsourcing providers
Why do healthcare providers prefer RFPs?
Key factors driving health systems towards a competitive route over sole-sourced are:
Unlike the pre-COVID era, when outsourcing was, typically, limited to a revenue cycle function or segment, the new deals coming in the Revenue Cycle Management (RCM) market are broad-based and many times encompass the end-to-end revenue cycle needs of healthcare providers. Given the size and scale of such deals, healthcare providers prefer the competitive route to get the best possible deal
While cost used to be the primary decision-making driver, health systems are now emphasizing deal aspects such as innovative pricing (wanting third-party providers to have skin in the game) and offering diversified delivery network, innovation pool commitment, and compatibility with existing infrastructure, including experience of working with platforms such as Epic
With hundreds of outsourcing providers in the RCM market, health systems know they can shop around to get the best deal
Key decision-making parameters for health systems in a competitive bid
Healthcare provider enterprises are looking for service providers who can provide end-to-end services covering the entire gamut of Revenue Cycle Management (RCM), rather than discrete, siloed services.
From a decision-making perspective, below are some of the key parameters that enterprises look for when selecting a potential service provider, along with their relative importance rated on a scale of 1 to 10:
Exhibit 2: Level of importance of key buyer decision-making parameters for outsourcing Revenue Cycle Management (2021)
Source: Everest Group’s coverage of major Revenue Cycle Management (RCM) providing enterprises
Service providers need to pay special attention to how they position themselves effectively in the extremely competitive RCM market. The two main levers determining a winning proposal are:
High-quality, well-structured proposals that demonstrate a deep understanding of the client’s needs
Commercial proposals that are well aligned with the client’s budget and offer flexible payment terms
As competitive RFPs rise in the RCM market, providers who can create a differentiated value proposition and align their strategies with the enterprise’s vision will succeed in securing these lucrative deals.
With member experience being critically important to healthcare enterprises, HealthEdge’s acquisition of Wellframe bodes positively for the merged enterprise and consumers. Read on to learn why we like this deal and the synergies between these two health services providers.
HealthEdge’s acquisition of Wellframe announced last month propels the provider of next-gen integrated solutions to health insurers into the high-growth digital member experience market. The deal will bring various benefits to HealthEdge, including Wellframe’s consumer-facing and user-friendly mobile application serving more than 33 million members that delivers personalized content and facilitates seamless connectivity to health plan staff.
The strategic intent behind the deal
In a recent (2020) survey by Everest Group, experience was identified as the most important strategic priority for enterprises. Member engagement has become an important area of investment for healthcare payers. Member experience as a theme is so important that health plans have created a new position, the Chief Experience Officer (CXO), to use their organizational muscle for prioritizing experience.
Healthcare payers realize that great member experience will not only help insurers in smoother acquisition and retention of clients but will also improve their financial performance by reducing the churn rate, improving health outcomes, and saving administrative costs. The industry is also witnessing a shift in the definition of “engagement” from being focused solely on sales and marketing to becoming a holistic approach across the three areas of sales and marketing, services management, and care management.
The acquisition of Wellframe propels HealthEdge into the large and fast-growing digital member engagement market. Coupled with its existing products, this creates a highly differentiated end-to-end solution for customers.
Unpacking the companies’ synergies
Wellframe’s Digital Health Management platform enables health plans to modernize member-facing services, including care management and advocacy. Wellframe’s Digital Care Management (DCM) solution serves as a digital front door for health plans seeking to engage high-risk members. Wellframe leverages real-time member-generated data and artificial intelligence to identify intervention opportunities across its solution suite.
Wellframe’s data sets of 33 million members combined with HealthEdge’s existing data sets will enable HealthEdge to focus on improving the quality of its insights, helping it not only in care management and member engagement but also in other areas where HealthEdge has traditionally offered services.
The Wellframe acquisition strengthens HealthEdge’s portfolio of SaaS solutions across payer workflow operations. The addition of Wellframe to its portfolio of care management solutions coupled with its existing GuidingCare® solution will enable a full spectrum of services spanning member identification, prioritization, targeting, and member engagement. Additionally, seamless and real-time integration between HealthRules Payor® and Wellframe will generate actionable insights that can lead to real-time member interventions and features that enhance a member’s health plan experience.
Things to watch out for
The acquisition of Wellframe is a strategic fit for HealthEdge to enter the high-growth member engagement market and compete with incumbents in this space, such as Salesforce and Pegasystems.
We are positive about this deal, particularly for what it means to the market and current market demand. However, it remains to be seen if HealthEdge also makes an entry in the other areas of member engagement, such as sales and marketing and services management, which would deliver even greater value.
Reach out to me at [email protected] with your thoughts on this acquisition or the member engagement market in general.