Two Payer Priorities in 2021: Member Growth and Provider Networks

In the recent Health Payer Specialist article “The Biggest Challenges Facing Payers in 2021,” COPE Health Solutions CEO Allen Miller called out two areas.

1. Rising Demand

Enrollment on the ACA-mandated health insurance exchanges is expected to grow. Indeed, a proposal to increase subsidies and expand ACA insurance eligibility is part of the Biden $1.9 billion stimulus package.

High unemployment due to the pandemic is pushing up Medicaid enrollment while Medicare membership may be impacted by direct contracting, which kicks off in April. One less likely source of potential CIN growth: Lowering Medicare eligibility to age 60. Such a major change would be a “big lift” given the narrow majorities in congress.

Takeaway: Payers need to develop strategies, plans and programs that meet the needs and expectations of these different populations during the ongoing pandemic as well as afterwards.

2. Network Reassessment

Facing severe financial strain, some providers may retrench or close—leaving network gaps for payers and their members. Payers should be asking: “Do we have adequate access for our membership? Not just from a network adequacy and regulatory perspective, but for achieving our goals (such as) total cost of care, quality and member experience,” Miller says.

Networks in 2021 also will be stressed by pent-up need for non-COVID-19 health services. Many enrollees with chronic illnesses have deferred care, including some with cancer. “What is their plan when this begins to recede…and how are they going to pay for that?” Miller asks. “People are going to need interventions. People are going to need facetime (with doctors and nurses).”

Takeaway: Collaborating with a range of providers and community-based organizations will be fundamental to managing and caring for the flood of demand and overall sicker patient population.

For more insights into 2021 payer challenges and opportunities, read the article at Health Payer Specialist, a Financial Times publication. (registration required)