Most Health Systems Still Preparing for Exchange Enrollment, Finds New Study from PwC’s Health Research Institute

Report outlines strategies for capitalizing on health insurance expansion

NEW YORK, September 18, 2013 –With enrollment in new online insurance exchanges set to begin October 1 under the Affordable Care Act (ACA), hospitals and health systems have an opportunity to allay recent financial woes resulting from declining admissions, care moving outside of hospitals and reduced government payments. Yet, new research published today by PwC’s Health Research Institute (HRI) finds that, while the new customer base could provide a much-needed financial boost, few hospitals have developed comprehensive strategies to identify, educate and help enroll people in health plans sold through the new exchanges.

In the report, the first of a two-part series titled, “Health Exchanges: Open for Business,” HRI examines what’s at stake for health systems, physicians and other providers as millions of new customers enter the formal healthcare system for the first time. The report examines the impact of narrow networks on some hospital systems and provides a detailed look at the progress of two hospitals in identifying opportunities and preparing for risks.

HRI interviewed executives from major health systems that collectively represent more than 150 hospitals across 25 states, as well as national hospital associations and patient advocacy groups to understand their plans, progress and concerns related to participation in the 51 new state exchanges. Key findings include:

  • Many providers have been slow to promote the expanded coverage options. Health systems attribute delays in their enrollment efforts to multiple factors, including: “Reform fatigue”; the need to finalize contracts with insurers; the slow trickle of information from regulators; and the desire for additional regulatory guidance, especially in the area of outreach designations and certification requirements.
  • The newly eligible pose an enrollment challenge. If individuals do not understand which plan best fits their needs, it could impact the health of the patient as well as the revenue and reputation of the hospital. Many Americans do not fully understand the basics of health coverage, and exchanges will add another layer of complexity as 86 percent of individuals who purchase a health plan on the exchange will receive some government subsidy.
  • Narrow networks could leave some hospitals out. Some health plans include only select hospitals and physician groups in their exchange offerings in an effort to hold down costs. This enables health plans to offer lower premiums, but also may lead to higher out-of-pocket expenses.

“As the health industry moves from wholesale to retail, the customer takes center stage,” said Ceci Connolly, managing director, PwC Health Research Institute. “Outreach and education should be top-of-mind for hospitals and health systems, but many are still coping with operational issues to ensure readiness for open enrollment. These companies will have to shift into gear quickly to focus on their consumer strategies and how to attract and retain a diverse mix of exchange customers.”

Culled from HRI’s in-depth interviews and analysis, the report offers a list of strategies hospitals can use to quickly get up to speed with open enrollment opportunities, including successful efforts implemented by health systems across the country.

“Health systems that are slow to identify and help enroll the uninsured risk losing a valuable new business opportunity to the competitor across town,” said John Dugan, partner, PwC Health Industries Group and revenue performance management practice lead. “As they ramp up, it will be important to develop counselors who can properly educate soon-to-be insured consumers on their insurance options and match individuals to the right type of coverage.”

A full copy of PwC’s report, “Health Exchanges: Open for Business,” is available for download at


Note to editors: Any citations of this research must be attributed to “PwC’s Health Research Institute.”


About PwC Health Research Institute (HRI)

PwC’s Health Research Institute ( provides new intelligence, perspectives, and analysis on trends affecting health-related industries. The Health Research Institute helps executive decision makers navigate change through primary research and collaborative exchange. Our views are shaped by a network of professionals with executive and day-to-day experience in the health industry. HRI research is not sponsored by businesses, government, or other institutions.


About PwC’s Health Industries Group

PwC’s Health Industries Group ( is a leading advisor to public and private organizations across the health industries, including healthcare providers, pharmaceuticals, health and life sciences, payers, employers, academic institutions and non-health organizations with significant presence in the health market. Follow PwC Health Industries at @PwCHealth.


About PwC US

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This content is for general information purposes only, and should not be used as a substitute for consultation with professional advisors.


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Lisa Stearns
The Hubbell Group, Inc.
(781) 878-8882