Payer & Payvider Research

KLAS represents the voice of healthcare payers and payviders. KLAS performance data and reports are made possible because many healthcare payers and providers take the time to share with KLAS their experiences and candid feedback about the reality of healthcare technology solutions and services.

 
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Why do Payers engage with KLAS?

Finding value in our data

Healthcare payers use KLAS data to make better technology decisions. KLAS' ongoing research into healthcare and payer industries provides real user perspectives on the technologies payers and payviders are using to impact their businesses.

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What is the benefit for you?

Accessing KLAS

When a payer engages with KLAS, they receive access to KLAS data that is collected from healthcare providers and payers. This means access to industry reports, user commentary, and real-time ratings. Much like the tens of thousands of healthcare providers who participate with KLAS, payers can access all of these benefits in exchange for being willing to share their experiences with the vendors and services they use.

Payer IT Research Areas

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Payer Claims/ Administration Platforms

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Care Management Solutions

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Pharmacy Benefits Management (PBM)

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Price Transparency Solutions

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Vendor Consulting Services for Payers

Payer Reports

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Though core administration platforms are essential for payer organizations, many of the products in the market are perceived as outdated, complex, and low performing (the market has one of the lowest average performance scores of any KLAS measures). However, HealthEdge has recently seen increased attention from both small and large health plans, who view the vendor’s technology as innovative and who have been asking KLAS for vendor insights. This report examines the experience of HealthEdge customers and how the HealthEdge technology stands out from competitors’.

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Along with buzzwords like “AI” and “population health,” the term “digital front door” has become more popular but lacks a consensual definition. For this study, KLAS spoke to 27 leading organizations to understand what digital front door means to them, what digital front door strategies and key technologies they use, and what outcomes they have seen. Based on the lessons they have learned along the way, these organizations (most of which use Cerner or Epic for their core EMR) also shared advice for peers seeking to build or improve their digital front door strategies.

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Analytics and risk adjustment are hot topics due to the expenses associated with value-based care, government regulations, and CMS programs. Pareto Intelligence’s revenue integrity solution attempts to provide organizations with actionable data to improve their risk documentation outcomes. This report examines the Pareto customer experience.

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In the past, payers have struggled with vendors’ care management solutions not keeping pace with functionality and support needs. Recent market shifts, such as M&A activity and leadership and ownership changes, along with the need for better payer/provider collaboration have created energy and optimism around the future of some vendors. Which vendors are stepping up, and which are missing the mark? This report focuses on how well vendors are helping organizations achieve desired outcomes through delivery of needed technology, excellent support and service, and follow-through on promises.

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The COVID-19 pandemic greatly accelerated healthcare delivery organizations’ adoption of telehealth and virtual care technologies. As these organizations scrambled to meet the immediate demand, they quickly implemented solutions that often required few resources and met focused needs. At the same time, vendors quickly pivoted to either develop dedicated telehealth products or add telehealth capabilities to existing offerings, creating a sea of options. This study, along with additional <a href="/category/telehealth-ecosystem/41"><u style="color:#005cb9;">deep-dive content on KLAS’ website</u></a>, shows which vendors report the broadest telehealth capabilities and aims to help organizations navigate different options as they look to consolidate systems and define their long-term telehealth strategy. For reader ease, links to relevant online content are provided where applicable. <strong>Note that the vendor-capability data in this report is based on vendor-reported information.</strong>

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The initial explosive growth of ACOs sparked by the Affordable Care Act has since tapered off due to uncertainty about how to move into downside risk. Over the years, several services firms have emerged to help provider organizations with the setup and ongoing management of ACOs. This report shares client feedback on how effectively and quickly these firms drive clinical and financial impact and prepare clients to take on more risk.

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Vatica Health provides dedicated clinical support and technology to payers’ contracted physicians to improve diagnostic coding, documentation, and quality of care for members. Vatica Health’s team works on-site to lend providers support, enabling payers to manage members and their care while also increasing financial impact and reducing compliance risk.

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Provider organizations have begun to consistently ask who, if anyone, can be a one-stop shop for patient engagement—allowing organizations to consolidate vendors and create a unified patient experience. Directed by the voices of provider and vendor executives, along with patients themselves, KLAS has helped the industry define “patient engagement platforms” through a series of reports and summits. This report is a culmination of those efforts, intended to help provider organizations understand who they can turn to for all (or almost all) of their patient engagement needs. Included in this study are insights from 153 of the broadest-adopting customers across 33 vendors.

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In October 2020, Teladoc Health finalized a deal to acquire Livongo. This merging of two publicly traded virtual care companies creates a telehealth giant amid rising demand for virtual care solutions. In July 2020, Teladoc Health acquired InTouch Health, another telehealth company. This KLAS Flash Insights report will share reactions from customers of all three vendors to the Teladoc Health/Livongo merger and their perception of what impact it will have. KLAS interviewed 30 individual clients—of these, 11 use InTouch Health, 11 use Livongo, and 14 use Teladoc Health (some organizations use two of these vendors’ solutions, but none use all three).

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MedeAnalytics offers a cloud-based analytics platform designed to help healthcare providers and payers make data-based decisions. Provider organizations utilize MedeAnalytics’ SaaS solutions for patient access, revenue integrity, business office, and value-based care, while payers use them for employer reporting and healthcare economics.

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In early 2020, KLAS published our first look at digital fax solutions. That report examined satisfaction feedback from the most advanced users of four digital fax solutions. Data for several other vendors, including Updox, was too limited to be shared at that time. However, additional advanced Updox customers have since been interviewed, and this addendum examines their customer experience.

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In the risk adjustment and analytics space (solutions and services supporting population stratification, reporting, and/or analytics for CMS or other risk-based contracts), four vendors tend to dominate mindshare and market share—Change Healthcare, Cotiviti, Inovalon, and Optum. But market share is not a guarantee of a strong customer experience, and some organizations have started to consider and choose other options. This report shares available vendor options, market perceptions of the most prominent vendors, and an early look at how well vendors meet client needs and drive outcomes. As KLAS research in this market is early, most satisfaction data is limited.

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A core administration platform is the transactional heart of a payer organization—it is used to enroll new members, process and pay claims, and manage product lines and benefits. Many of the products in this market, while needed and typically stable, have been around for decades and are highly customized, hosted on-premises, and often seen as old and complex. Many payers are therefore reluctant to replace these systems because the risks and required effort are so high.<br /><br />But recent buying activity suggests the payer core administration platform market is seeing revitalization. Triggered by the opportunities and challenges of payment reform and value-based care, payers are looking ahead and starting to bid for new vendor partners. <br /><br />KLAS spoke with 30 payer organizations who are making or have recently made purchase decisions, and they shared their candid feedback and insights regarding what vendors they have considered, selected, and/or replaced. These interviews reveal new energy and life in a market long overdue for change—in terms of both product and service delivery. 

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Despite reduced regulatory pressure, competitive and financial factors continue to drive organizations toward value-based care (VBC), yet making the transition is a complex and expensive undertaking, especially for smaller or midsize organizations, who may lack the resources and expertise of their larger peers. An array of services firms and software vendors offer managed services designed to help. These offerings vary widely, and provider organizations will want to consider several factors when choosing the firm that is right for them. This report examines eight services firms and software vendors who offer VBC managed services to examine the types of projects and organizations they work with and how well they perform.

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Transitioning from fee-for-service to value-based care (VBC) is a top-of-mind concern for healthcare organizations. However, <u><a href="/report/healthcare-management-consulting-2018/1278" data-id="1278" data-itemtypeid="7">previous KLAS research</a></u> has revealed that VBC transformation is also the area in which healthcare executives are least familiar with which firms are well positioned to help. This report examines nine firms that provide value-based care consulting services to explore the types of work these firms do (and for who), how consistently the firms perform across clients, the outcomes they deliver, and the factors that drive these outcomes.

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<p>While utilization management and care management solutions have been around for decades, today health plans are looking for modern technology solutions to help them manage multiple business lines and adapt to changing requirements for value-based care. While innovation overall in payer HIT is not abundant, KLAS has seen an increase in decision energy mostly from relatively or completely new vendors receiving stronger consideration than existing or established vendors.</p><p>KLAS defines payer care management solutions as systems comprising functionality in areas like utilization management, case management, disease management, and care coordination. 40 unique payer organizations shared insights with KLAS about their purchasing decision process, including which vendors they considered, selected, and decided to replace. As validated in this research, future-state goals (noted below) are becoming increasingly important in these decisions.</p>

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Demand for payer IT consulting services continues to rise as changing market regulations have increased the need for improved efficiency, accurate software, and ways to navigate the complex market environment. This report, KLAS’ first in the market, offers transparency into what payer IT consulting firms offer and their performance, including expertise and adaptability to customer needs (i.e., being flexible in approach and staffing and agile in making changes). At a high level, healthcare-specific firms are delivering more guidance and flexibility than cross-industry firms, though there are exceptions to this trend. 

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In the tens of thousands of interviews KLAS conducts with healthcare providers on an annual basis, new companies or solutions are sometimes revealed as taking new or innovative approaches to solving some of the problems faced in healthcare today. This report shares the top-of-mind companies that surfaced during our emerging technology research interviews with provider organizations across the country in 2018; KLAS will continue to monitor those companies that continue to pique provider interest.

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The Best in KLAS designation is reserved for vendor solutions that lead those software and services market segments that have the broadest operational and clinical impact on healthcare organizations. These vendors earn the title of Best in KLAS—a recognition of their outstanding efforts to help healthcare professionals deliver better patient care. Separate from the winners of Best in KLAS, Category Leaders also earn top honors for helping healthcare professionals provide better patient care. The Category Leader designation is reserved for vendor solutions that lead select market segments in which at least two products meet a minimum level of KLAS Konfidence.

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The primary goals of this perception report will be to identify management consulting firms who can help meet healthcare executives needs not only now, but in the future as well. We will highlight the breadth of their capabilities and the depth of their healthcare expertise. Additionally, we will uncover the emerging consulting needs of providers and the attributes they value in a consulting firm.

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When purchasing a population health management (PHM) solution, provider organizations can choose from three general types of vendors, each of which comes with a potential disadvantage. Organizations can (1) choose from the established vendors, who tend to have lower overall customer satisfaction; (2) start with their EMR vendor, though EMR solutions can be immature and lack the required functionality depth; or (3) select an upstart company—though their potential can be alluring, these vendors lack a proven track record. In a rapidly evolving market where few vendors deliver as much as they promise, what are the best options available? Which PHM vendors have high market consideration, above-average customer retention, or high customer satisfaction? And do any vendors have all three? 

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Ever-evolving HEDIS metrics continue to demand payer attention, but annual quality reporting alone is not an effective way to close care gaps or reduce costs. Health plans have repeatedly expressed a need for more frequent HEDIS reporting and deeper analytics capabilities that enable them to empower proactive care interventions and improve outcomes for their members. KLAS asked 84 health plans which vendors go beyond the required HEDIS check boxes to help clients forecast risk and improve quality.

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The need for partners is stronger now than it has ever been as healthcare organizations continue their journey to provide seamless care across the continuum, shift from fee-for-service to fee-for-value, reduce costs, and ultimately improve patient care. KLAS has published numerous reports on a wide range of consulting services, but this is the first that focuses on which firms healthcare organizations consider true partners. KLAS interviewed decision makers from 246 healthcare organizations about the consulting and services firms they have used to discover which they consider true partners and which they would avoid using again.

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With healthcare costs at unsustainable levels, the industry finds itself on a trajectory from fee-for-service to value-based care. Provider organizations who aren’t prepared to manage cost and take on risk while also maintaining or improving quality will have a hard time surviving. In this first-time report, KLAS takes an early look at the various ways organizations that already have a strategy are tackling this challenge and what vendors they are using or considering to help them. Interviews were conducted mainly with C-level executives, mostly from organizations with 500+ beds. Only the strategies and vendors most commonly brought up in interviews are discussed below.

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This first-time KLAS report takes an early look at the vendor solutions used for health insurance exchanges and insurance enrollment in the ACA market. Faced with the uncertainty, political instability, and complex regulation that characterize the ACA market today, healthcare payers are searching for vendors who can help them successfully weather the storm. Based on interviews with healthcare payer executives, this KLAS report gives initial but important insight into how well—or poorly—some of the key solution vendors are meeting needs.

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Many health plans today are faced with rapidly changing regulations combined with middle-of-the-road performance from their core claims and administration vendors. Citing poor service and support, old technology, and nickel-and-diming, these health plans are looking for improved innovation and the ability to quickly adapt to industry changes.

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The opportunity for customer relationship management (CRM) to have a meaningful impact in healthcare is growing. However, managing relationships with current and prospective patients and physicians often requires new workflows and access to consumer data not typically tracked in healthcare today. Even as this nascent market is still being defined, many vendors claim to help in a myriad of ways. This report will explain which of the most common niches vendors are being used in as well as help providers understand their peers’ current overall satisfaction with vendors’ technology and service.

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New market demands are pushing health systems to take on more risk, resulting in some starting their own health plans. These provider-owned health plans (“payviders”) and other full-risk-bearing organizations like them rely on vendor solutions for core payer functions, yet many of the platforms are decades old. How well do these solutions perform, and will new entrants shake up this reemerging market?

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It’s been five years since Medicare kicked off an industry-wide transition from fee-for-service reimbursement to a system that rewards quality rather than quantity. Commercial payers are following suit, and providers expect participation is inevitable. Some providers are adopting value-based care (VBC) initiatives in an attempt to remain competitive, while HIT vendors are counting on VBC as a revenue stream. Based on 173 provider interviews, this report examines the progress of VBC and which HIT vendors and solutions are making a difference.

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