The Evolution of Use Cases in the Care Management Market - Cover

The Evolution of Use Cases in the Care Management Market

Otherwise known as medical management, payer care management is an area that continues to be important for payers throughout the US market. Care management solutions offer analytical tools and workflow features that assist healthcare payers in managing their members’ health conditions. Seeing progress and innovation in this space is also equally important to payers; many payers feel vendors have a lot of opportunities to improve, noting persistent integration and functionality challenges.

Over time, care management vendors have developed additional functionality and technology, allowing their payer customers to move beyond traditional use cases like case management and utilization management, into emerging use cases like behavioral health and automated payer authorization. We recommend reading the recent Payer Care Management 2023 report to see which vendors are building strong customer relationships, innovating their technology, and facilitating further customer adoption.

Relationships an Important Factor for Payer Customers 

Data for the payer care management study comes directly from experiences payers have shared with KLAS. The insights show a correlation between the relationship score and the overall performance score, as shown in the below chart. Many payer customers highlight the importance of having a good relationship with their care management vendors, with the data showing that the relationship has a significant impact on how customers feel about the vendor overall.

overall performance score vs relationship

Vendors who score high for relationships are noted by respondents for having good executive involvement, support, attitudes around jumping in to solve problems, and customization capabilities, among other things. On the other hand, vendors who score low are noted for slow responses, staff turnover, and lack of expertise. Building relationships with customers can help lead to long-term customer loyalty in this market.

Care Management Growing with Emerging Use Case Functionality

In recent years, emerging use cases have been in the spotlight in the care management market. This includes both emerging clinical use cases (e.g., behavioral/mental health, pharmacy management, provider engagement/collaboration, virtual care, and telehealth) as well as emerging administrative use cases (e.g., appeals/grievances, automated member outreach, risk strategy and data reporting, social determinants of health).

Still, as a whole, care management vendors struggle to provide the functionality that payer customers want and need. However, there are vendors who stand out for broader support of several use-case functionalities. Vendors have an opportunity to better provide the technology that payer customers need while also improving the efficiency of the technology that is already in place. The report shares more information on vendor performance in this area and validations of these emerging use cases.

Purchase Energy Varies among Care Management Vendors

There are many players in the care management market, with integration to payers’ claims and administration platforms being one of the top factors in considering or replacing a vendor. Consideration energy varies among the different vendors.

In the past two to three years, HealthEdge leads in considerations, and respondents often cite the historically strong functionality and expected future integration with the core claims solution as a main consideration factor. Other commonly considered vendors include ZeOmega and Zyter, who are well known in the market and are noted by respondents for their expertise and reputation. See the report for more information on other vendors’ consideration energy and score for part of long-term plans.

The Care Management Market into the Future

In the future, we anticipate the energy in the care management space to continue to grow as new vendors enter the market and as vendors continue to create new functionality. As an example, there is an overall universal desire to add more interoperability through FHIR-enabled APIs; some vendors are already working in this direction, while other vendors may not have the same priorities. The heavy emphasis is on improving the integration between care management platforms and core administration platforms, and that is very likely to continue and affect more decisions going forward.

As mentioned above, vendors need to continue to enhance their customer relationships. KLAS will continue to measure care management solutions and assess customer perception and vendor performance in this space. Additionally, look forward to the Best in KLAS report in early 2024 to see what progress health plans do or do not see with their care management vendor partners.

Photo credit: Delmaine Donson/, Adobe Stock