Do any of these challenges sound familiar? See each issue from a new angle and read about solutions that PwC has to offer.
U.S. Healthcare is among the world's most heavily regulated industries. Payers must comply with a myriad of federal and state laws and regulations. These include rigorous auditing and reporting requirements, HIPAA privacy and security mandates, complex and restrictive rules and payment formulas for Medicare and Medicaid products and ICD-10 coding requirements. Anticipating the rules and regulations you must follow poses complex challenges. Assuring compliance on so many fronts severely strains your resources. Ever-increasing scrutiny from state and federal regulators amplifies the stress.
Despite the efforts of payers to reduce waste, fraud and abuse, and to encourage cost-effective, evidence-based treatments, healthcare costs continue to rise to unsustainable levels. Payers must continue their leadership role in driving quality up and costs down. Regulators and other stakeholders demand transparency and value. Mere compliance with regulations will not suffice. Payers need rigorous financial controls to prevent fraud and reporting errors. A corporate culture that weaves compliance and risk management into business operations. Employees who take personal responsibility for regulatory compliance and intelligent risk management.
An aging population. Longer life expectancy. Demographic changes are expanding the market for health insurance. But who will pay? Corporations are cutting health benefits, most of all to retirees. Health insurance is being driven into a direct-to-consumer business. Rising unemployment is shrinking the commercial insurance market. And reforms from the Obama administration such as a new public health plan or expansion of Medicare could crowd private plans out of the market and reduce the pool of potential customers. Payers need to adapt to these epochal changes in the commercial insurance marketplace. Introduce new benefit models to proactively anticipate and address the needs of targeted sub-markets such as retirees, young workers and the growing ranks of the unemployed. Develop new products and reshape existing ones to attract consumers demanding quality and value. Consumers who want to stay healthier longer, for less money.
The right products can bring you new customers and deepen your relationships with existing ones. For example, you can offer:
Once you develop market-savvy plans, you must carefully assess risks to price them appropriately, and then devise strategies to market them effectively. Direct the efforts of your product development to get to market more swiftly than your competitors with quality products that add value to the consumer's healthcare experience.
Global Human Resources Services
Consumer choices, government mandates, loss of key accounts to a troubled economy and the possibility of healthcare reform all amplify the relentless pressure on payers to grow revenue and shrink costs. Restrictions on coverage options and premiums will challenge payers to profit from these new members. Keeping plans attractive and affordable will mean driving value up and costs down.
To remain competitive, you need to improve your operational performance. Integrate your information systems throughout your enterprise. Conduct transactions more collaboratively and seamlessly with other stakeholders. Streamline your administrative processes. Understand that performance improvement is more than a strategy for growth - it is a tactic for survival.
US Healthcare Payer Practice
A worldwide economic recession. A constricting marketplace. New, global competitors. A shrinking commercial insurance market. Proposed policy reforms that could potentially reshape every aspect of the health insurance industry. Payers face daunting challenges. As always, you must respond to relentless pressure to grow revenue and shrink costs. In today's volatile economic and political climate, you share with other stakeholders the burden of transforming an unsustainable healthcare system. Stakeholders are still working to reach consensus on the nature of the transformation and the details of how to achieve it. The payer balance between public and private has yet to be determined. New regulations and new marketplace realities are already changing the way you sell your products, and to whom.
Economic and demographic trends drive the transition away from employer-based health plans to an individual-based market for health benefits. Although proposed mandates and tax credits would enlarge your customer base, there will also be constraints on your profit margins. The federal government's likely expanding role in healthcare could lead to caps on premium increases, coverage mandates, limits on your insurance underwriting strategies and other regulatory burdens.
US Healthcare Payer Practice
You want to leverage IT for competitive advantage.
Employers, members, providers and many other stakeholders can all benefit from enhanced information technology. You want to use enabling technologies to increase customer loyalty, improve quality, reduce costs and add value to the healthcare ecosystem.
You want to plan, prioritize and execute IT projects to align with your business strategy.
The list of IT initiatives is endless. You want to align potential projects with your organization's business strategy and budget to focus on those with the highest value. Then plan and execute with methodical precision to deliver on budget and on time. It's no secret that there is a high failure rate with large-scale implementation projects, so you want to use a proven risk-management framework to periodically assess the progress of your initiative.
US Healthcare Payer Practice