Healthcare Payor Trends to Watch in 2023

With inflationary concerns hitting every sector of the economy, healthcare is no exception. Employee benefits costs are also expected to increase 5.6% in 2023, on top of an expected healthcare labor shortage in the new year (according to a report from McKinsey). Add slower than expected post-pandemic healthcare utilization rates to the ongoing billions of dollars of losses annually due rampant fraud, waste, and abuse throughout healthcare, everyone in the healthcare ecosystem is feeling the squeeze.  But there are bright spots and reasons for optimism. Here are a few on our radar in 2023:

AI and machine learning become more mainstream among health payors 

Approximately 30% of the world’s data volume is being generated by the healthcare industry according to a RBC Capital Markets report. To keep pace with the vast amounts of healthcare data, payors need to make machine learning (ML) and AI investments a priority or be left behind. Both hold tremendous potential for driving down healthcare costs by battling FWA and creating workforce efficiencies. Look for payors to ramp up the speed to deployment to leverage the massive quantities of incoming data from diagnostic codes, patient data, anomaly detection, and more. 

Transparent pricing and NSA confusion will stick around, but solutions have emerged 

As healthcare payors continue navigating the complexities of implementing the No Surprises Act (NSA), many have realized it is time-consuming to comply. As larger payors work to address breakdowns in internal workflows that emerged in 2022, they’ll rely more on the expertise of solutions from vendors.

Successful outsourcing can be found to help payors with qualifying payment amounts (QPA), especially as related to reference-based pricing plans. Managing the independent dispute resolution process will continue to be an outsourceable function, and we’ll see solutions in managing machine-readable files (MRFs), which are required by the Transparency in Coverage (TIC).

Employers look for cost-savings and effective employee benefits 

Employers will continue looking for ways to lower employee healthcare benefits costs without sacrificing quality care. 64% of employers said they’ll re-evaluate their benefits plans to address healthcare costs over the next two years, according to survey data from Willis Towers Watson. Today’s tight labor market is also placing higher significance on lowering employee healthcare costs. In a survey from SHRM’s Employee Benefits Summary, most employers surveyed feel healthcare benefits are the most important type of benefit an organization can offer.

Cost-containment tools like value-based plans are increasingly being adopted by employers, including reference-based pricing plans. Industry estimates forecast we’ll see the current 4-5% of claims processed with reference-based pricing jump to 15-20% in the next two years. It can also incentivize employees to seek health care, who might not have, due to the cost.

As we start the new year, we will see payors, providers, and consumers collaborating to improve the healthcare experience. Improvement may mean technology alignment, consolidation and consumerization, or transparent cost and ease of getting care. But one thing is a sure bet, healthcare will remain a dynamic industry with creative solutions emerging throughout 2023 and beyond.

Ryan Day

Ryan Day, President, HST, a MultiPlan Company, oversees operations and product development, bringing to HST an extensive background in finance, developing innovative technology solutions, and strategy. He started his career with a boutique Wall Street firm specializing in investments and employee benefits for nonprofits and hospital systems.

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