The traditional healthcare business is fading into the sunset, along with its complex product structures, incomprehensible reimbursement models, and confusing industry jargon. A new day is dawning, and opportunities abound for the players that are prepared to pursue them.
The U.S. healthcare system suffers from excessive costs and wasteful spending, and it is growing at an unsustainable rate. The Patient Protection and Affordable Care Act (PPACA, often shortened to ACA or Obamacare) holds payers accountable for controlling costs. While some costs are beyond the scope of what payers can solve, much of the spending is well within their control. With the spotlight on consumers (patients) and on reducing costs, the balance of power and risk is shifting — and it is calling into question the traditional roles of employers, payers, and providers (see figure).
Figure: Today’s Complex Healthcare Landscape
As the days of business-to-business (B2B) healthcare come to an end and the market becomes more consumer-centric, the players that remain must evolve to stay afloat in this human-to-human (H2H) world.
As introduced by the Triple Aim framework, the healthcare system requires all players to participate with shared incentives to drive change and help patients see healthier, more affordable outcomes. This requires deep analytic capabilities to integrate data across myriad sources (including providers, patients, and medical histories), to assess personalized risk based on demographics and treatments, and to create informed recommendations to control cost and improve care. Who will orchestrate this? How will shared incentives be structured?
The future of healthcare depends on an integrated, collaborative environment producing high quality at an optimized cost. It is unclear exactly how we will get there or who will win or lose. In this uncharted territory, there are still many unknowns — from the balance of risk and cost to the future of employer-sponsored care, the political landscape, and the bipartisan tug-of-war.