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The health insurer of the future: Consumers’ advocate, providers’ partner

As powerful forces reshape healthcare, health insurers should make choices now about business model changes that will position them to prosper in the future. Strategies that build resilience will focus on what is known – healthcare’s increasing drive to be value-based, consumer-focused and technologically-enabled.

To thrive in the New Health Economy, health insurers will need to embrace these trends. They will need to adopt new ways of doing business, rather than tinkering with the traditional model. PwC’s Health Research Institute (HRI) has identified five models for the health insurer of the future that balance better engaging consumers and collaborating with providers to help keep the cost of care down.

Five models of the health insurer of the future

Consumer advocate

The consumer advocate health insurer simplifies plan designs and offers consumer-friendly tools such as instant pricing, allowing consumers to compare true prices for treatments. This health insurer – often digitally enabled – empowers consumers to make smarter healthcare choices.

Bridge connector

The bridge connector model facilitates the relationship between patients and care providers. These insurers play an active role in getting consumers care. They use technology to help providers anticipate consumers’ needs and work with consumers to adhere to care protocols.

Lean operator

Most similar to today’s insurer, the lean operator seeks to maximize efficiency in, and reduce costs of, administrative tasks such as claims administration, utilization review, premium collection and enrollment oversight. Instead of building capabilities to connect with consumers and improve care delivery, lean operators seek partnerships with new entrants that achieve those goals.

Analytic sensor

The analytic sensor health insurer capitalizes on the industry’s appetite for data and analytics by positioning itself as a source of these essentials. It offers technology platforms that give clinicians and other stakeholders insights into the health of patients and patient populations. Analytic sensor health insurers can bundle their solutions into a higher-margin service offering to establish a non-regulated line of business.

Care integrator

The care integrator health insurer is merged with a provider, sharing risk while controlling cost and quality. By combining health coverage and care delivery under one roof, care integrators align health insurer and provider economics, giving incentives to reduce unnecessary care, improve outcomes and keep the total cost of care in check.

What this means for your business

Focus on the fundamentals to build trust. Consumers and providers continue to have low levels of trust in insurers, a major barrier to overcome. Doing so will require that insurers focus on the fundamentals – delivering digital tools that are easy to use and  rethinking core functions like prior authorization which have contributed to the lack of trust.

Balance technology with a human touch. Consumers want to speak to a person when making health decisions. These interactions cannot be replaced by technology. The health insurer of the future should, instead, invest in technology that supports and enhances such interactions.

Help providers focus on delivering care. By supporting and automating processes like patient eligibility and prior authorization, insurers can relieve some of providers’ administrative burdens. Doing so will help insurers establish goodwill with providers — sending the message that they are partners — and will give providers more time to focus on their most important job: caring for patients.

Hire or borrow the right talent. The health insurer of the future will need to diversify its workforce with people from industries such as tech, hospitality and social services. The health insurer of the future will need workers with customer service and people management skills as well as those experienced in data analytics and advanced technologies like artificial intelligence and blockchain.   

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Greg Rotz

US Pharmaceutical and Life Sciences Advisory Leader, PwC US

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