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Payer Care Management: Vendors Could Do Better

In the clinical world, there are EMRs that contain vast amounts of data, and there are population health systems that help make sense of that data in a cool way to actually benefit the patients’ health. In the payer world, the core claims platform and the care management platform work together in the same way—the core claims platform collects all the data about a payer’s members, and the care management platform takes all the data and helps the payer figure out how to best help their members.

It’s like an SAT question: population health is to the EMR what care management is to the core claims platform. (There’s your SAT throwback for the day.) The problem is that payers often can’t figure out what all the data means in their core claims platform. And that is where vendors in the space can step up their game.

Out with the Old, In with the New

Before diving into how vendors should step up their game, let me first provide some background. Many vendors that sell a core claims product also provide a care management platform, similar to how several EMR vendors also sell population health products. Because of that, many payers are asking whether they should buy a vendor’s care management solution along with their core claims solution, since that is an easy way to go.

In the Payer Care Management 2019 Decision Insights Report, we wanted to break down the data into who offers both products and who offers only care management products. We also wanted to see how the vendors who have been around a long time and provide both solutions compared to the newer vendors.

We found that AssureCare and VirtualHealth, some lesser-known vendors, are getting a lot of attention and consideration when payers are making decisions about care management software. Surprisingly, people are paying attention to some of the newer entrants, even the ones that don't offer a core claims product.

These lesser-known products are making some noise in the market, and the products are getting more and more looks. But what about the products from the big-boy vendors, the ones who have been around for longer?

I think some of those bigger vendors who sell core claims platforms and care management platforms have been taking the state of the market for granted. They have been ignoring some of the newer vendors who have come into the space and who have claimed that they can do things with payer data that no one else can do.

These newer vendors are disrupting the space, and maybe that is just because they are hungry for business. But this is an opportunity for all vendors to step up to the plate and really work with payers to give them what they need. Because in all reality, no vendor is doing so hot.                 

The Best Is Just . . . Okay

If you look at the scores for all the vendors in the payer care management space, none of them is above an 80, which is pretty sad. That means most payers are getting a C+ experience. No vendor is knocking things out of the park.

Client satisfaction is declining, even for the top products within the segment. Payers want a great product that really delivers. Right now, the care management market is interesting, but there isn’t enough innovation happening. There has been an increase in decision energy, but there is no clear leader of the pack who is doing really well.

Satisfaction Ratings Are All Across the Board

Similarly, when it comes to post-purchase satisfaction, customers’ ratings are all across the board. It isn’t surprising when vendors have customers who are really happy and customers who are really unhappy, but it’s intriguing that the satisfaction scores aren’t more clumped together and are instead spread all across the scale.

overall score distribution of customers (after purchase)

Basically, you could close your eyes and randomly point on the scale, and no matter where your finger landed, you’d be pinpointing some customer’s satisfaction. For each vendor, there isn’t one dominant customer group that is happy or upset.

Most of the time when I collect research over the phone, I have a sense of how the conversation will go before I even pick up the phone. I can usually detect whether someone will be wildly happy or wildly angry. But that is not the case with the care management space.

There isn’t a wide gap between the dissatisfied payers and the satisfied payers. There is a ton of variation, which is just fascinating.

Past Expectations versus Future Expectations

Although the variety in customers’ ratings is interesting, I think it is indicative of how the vendors in the care management space aren’t giving payers the necessary tools to succeed. There is definitely some room for improvement.

The vendors’ solutions that are in the market today probably meet payers’ expectations from the past. But now as we are moving toward the future, payers’ expectations are changing, and vendors should be adapting to those expectations to make their software even better.

For example, in the past, the approach to utilization management was very fragmented. It wasn’t super top of mind, so no one was really focusing on that. But payers are now looking for member-centric solutions that will help make their members better. Payers want to know how they can work with patient populations and individuals so that every member can see improved outcomes.

Another area where payers are looking for change is member engagements. In the past, payers kind of looked at claims through a rearview mirror and analyzed what happened. Now they are asking whether they can use predictive analytics and prevention methods to determine what might happen in the future. That would allow payers to proactively help their members be healthier.

Time to Step It Up

Even though payers want to see these changes and improvements in more than just one area, there is a gap in the payer technology. Not all vendors are embracing what the payers want, and instead, some vendors are giving payers old technology that doesn’t really meet their needs or desires. To read more about how different vendors are doing and to see payers’ remarks, be sure to check out the report.

If vendors were fulfilling payers’ needs, then payers would be much more satisfied. Hopefully we will start to see more of these care management vendors make adjustments and dig down into what payers want to see. Then we may finally see these vendors score above an 80. 




     Photo cred: Adobe Stock, Worawut