Although end-to-end digital claims management is still a distant vision, much can be gained from digitizing portions of the claims process today.
Hospital care is changing both rapidly and radically. Because of innovations in care delivery and organisational structures, future hospitals are likely to be very different from those of today.
Technology-driven innovation holds the potential to improve our understanding of patients, enable the delivery of more convenient, individualized care—and create $350 billion–$410 billion in annual value by 2025.
Addressing the social determinants of health: Capturing improved health outcomes and ROI for state Medicaid programs
The social determinants of health (SDoH) strongly contribute to variations in health status. Addressing SDoH can help ensure access to high-quality care, improve outcomes, and manage costs.
Survey findings shed light on how social determinants of health affect healthcare utilization rates and consumers interest in social program offerings.
Value-based care models are becoming increasingly important for health systems. Implemented well, they can improve system economics, enhance care quality and outcomes, and strengthen physician alignment.
Value networks and value-based payment are usually implemented independently, limiting their effectiveness. Greater alignment of these strategies can allow payers to unlock their transformative potential.
The Medicaid program has experienced significant changes since 2010, when the Affordable Care Act was passed. Five trends are likely to affect how the program will change over the next five to ten years.
Although the opioid crisis in the US is gaining increased attention, the steps taken to date to combat it are insufficient. Our research suggests that much broader—and bolder—action is required.
Since Star Ratings were introduced a decade ago, average MA plan performance has improved, quality standards have risen, and more people are enrolled in higher-quality plans.
McKinsey’s latest research suggests that although the market for individual insurance appears more stable from the consumer point of view, opportunities remain to encourage people to obtain coverage.
For countries that want to provide universal health coverage, defining the benefits package can be challenging. An analytical framework provides insights and action steps for emerging economies.
Having a strategy to attract and better serve patients with chronic disease will be critical for health systems to ensure growth in uncertain times.
Healthcare is a dynamic industry with significant opportunity, but cost concerns, uncertainty, and complexity can also make it an unnerving one. Substantial upside exists for players that can deliver value-creating solutions and thrive under uncertainty.
Medicaid’s scale and complexity are unprecedented. State Medicaid leaders will need to innovate if they are to develop the capabilities that will enable them to steer their agencies into the future.
Despite present uncertainties, MCO leaders can still aspire to grow—and make decisions to support that aspiration. Our research shows that the key sources of growth for Medicaid MCOs are strategic, not operational.
In this interview, Otto Bitterli (Chairman of Sanitas Health Insurance) discusses the company’s digital transformation and its commitment to being an innovative long-term partner to its customers.
A new McKinsey analysis suggests that overall carrier losses in the individual market were probably smaller in 2016 than in 2015 (7% to 9% of premiums, versus 10.1% of premiums).
The US health insurance industry continues to be defined by uncertainty. The 25 articles in this compendium can help health insurers navigate the changes ahead.
Pharmaceutical companies want to be rewarded for innovation, but rising drug costs are straining payor economics. This conundrum must be solved, not for one drug at a time but across the breadth of products in the pipeline.
Converging trends are disrupting the US healthcare industry. Health insurers are not likely to disappear, however, despite predictions to the contrary. Insurers that can take advantage of these trends are likely to find that their best years are ahead.
This paper explores opportunities states could consider to improve their Medicaid programs, both to control spending and improve the program's performance.
Increasingly, consumers are seeking services at sites of care outside of the traditional health system infrastructure. This shift has important implications for how health systems think about their asset base and scale.
To select which markets to focus on—both within health insurance and in adjacent businesses—payors must have strong market insights, the fortitude to make tough decisions, and the agility to alter course rapidly.
In our healthcare system, those in the best position to control risks and costs often have inadequate incentive to do so. Refining healthcare financing and reimbursement requires a deep understanding of the nature of medical risk.
Employers are showing increasing interest in new payment, delivery, and funding models. To capture the opportunity, payors must be able to target appropriate employers; educate employers, employees, and brokers; and demonstrate savings.
Four fundamental questions can help payors and providers improve productivity and better control utilization—the prerequisites for making value-based care sustainable.
A wide range of changes to stabilize the individual market have been proposed. This special report examines the impact some of the initiatives could have on claims costs and enrollment by the uninsured.
This new framework can help states improve their ability to design and contract for managed Medicaid programs for these individuals—and maximize the programs’ likelihood of success.
Four fundamental forces (risk, technology, regulation, and consumerism) are disrupting the overall trillion-euros-in-revenue global private health insurance market—a market experiencing substantial growth. Private payors must act on the imperatives resulting from these forces if they are to capitalize on the opportunities and avoid obsolescence.
The findings in this Intelligence Brief provide an introductory perspective on how the next US administration and Congressional Republicans may approach altering the ACA and related legislation. The information is based on publicly reported information released through December 8, 2016. Our Reform Center team is continuing to refresh this perspective on a real-time basis and is closely analyzing potential implications and economic impacts for each policy element under a full range of scenarios.
Two steps—increasing healthcare-sector productivity and improving healthcare-market functioning to better balance the supply of and demand for health services—would likely produce sufficient savings to lower medical cost inflation to the rate of GDP growth.
Traditional arguments for EHR implementation such as efficiency gains and meaningful-use incentives are insufficient to maximize a health system’s returns on its technology investments. However, clinically and operationally oriented sources of value can generate an additional $10,000 to $20,000 per bed in annual margin.
Although structurally simple to create, clinically integrated networks (CINs) are difficult to get right. Health systems considering establishing CINs must think through what it truly takes to create value through these entities and then make sure they have designed the CINs appropriately.
Changes in provider economics are requiring them to rethink their sustainable valuable propositions. Here’s how.
Digital technologies and applications have the potential to markedly enhance a payor’s profits. Leadership from the top is necessary to overcome the organizational resistance to change that can make a digital transformation difficult.
Offering a health plan can give health systems an opportunity for growth, but it is not without financial risk. To benefit from this move, health systems should use a different lens to understand both consumers and risk, know where the best growth opportunities are, rethink their payor-provider interactions, and take advantage of integrated claims and clinical data.
Many health systems are considering launching health plans, assuming that because they can deliver efficient, outstanding care and superior customer service, they will succeed with a health plan. This assumption is not always correct.
By offering its own health plan, a hospital system may be able to gain a variety of advantages -- but the move is not without risks.
Three primary ways in which cybersecurity affects enterprises - and the healthcare industry, in particular.
The healthcare industry is on the brink of sweeping change. The experience of other industries that have faced disruption suggests that a new set of winners and losers will emerge. Our research into these other industries reveals three approaches incumbents can use to thrive during and after a disruption.
We believe the payor industry has entered a period of discontinuous change. Traditionally steeped in slow cycles of annual group sales and multiyear product development, payors in today's market must significantly transform themselves in order to thrive.
Payors today must carefully select which markets to focus on—both within health insurance and in adjacent businesses. To determine this, they need insights into where growth and margin can be earned, the foresight to determine when market inflection points might happen, a clear view of their competitive advantages and capabilities, the fortitude to make tough resource allocation decisions, and the agility to alter course as the market shifts.
Historically, larger scale has offered hospital systems a number of advantages; however, reform and other market changes are altering the scale equation for hospital systems.
Whether scale brings competitive advantage to payors is a topic of hot debate. This post challenges standard assumptions about scale and sheds light on how to achieve desired value.
The power of where-to-compete decisions in the health insurance industry is enormous. How can organizations reap greatest benefit from these critical decision points?
This video discusses reform and the unprecedented change underway for payors.
This video highlights the variability of reform and the range of potential outcomes for payors.
For most health systems, the one-time impact of expanded insurance coverage on utilization will be small but significant. Systems that can capture a substantial share of the increase in utilization may gain a competitive advantage.
This series of articles examines transformational imperatives specific to health systems in the post-reform era, drawing on extensive work with healthcare stakeholders across the value chain.
This paper outlines five broad changes in the U.S. healthcare system and the likely strategic responses across the value chain.