The lines between provider and payer will continue to blur, with providers experienced with managing risk forming provider-sponsored health plans, and payers acquiring physician practices (to complement narrow networks), telehealth companies, and urgent-care facilities to become “payviders.” Expect the trend of providers moving into the payer space as Medicare Advantage plans and Medicaid waiver plans to continue to grow, especially for those systems that are already effectively managing medical expense and utilization, and now want to build premium and benefit management skills. We also expect to see the continued increase of providers forming captives as a complement to their clinically integrated networks (CINs), integrated delivery networks, and large physician organizations. These strategies can be complex but worthwhile to differentiate the system by designing coverage to meet its specific degree of risk-tolerance, creating better access to the reinsurance markets, and various other benefits that will eventually create value for both the employer and provider hats
On the “payvider” side, expect to see fewer payers purchasing heavy assets such as hospitals or large integrated delivery networks, like Highmark did when it formed Allegheny Health Network in the Pittsburgh market. Instead payers will be more focused on building a competitive network through the acquisition of high-performing narrow networks, management service organizations, and urgent-care centers in retail settings helping to elevate a “one brand” concept. We may also see payers becoming providers through purchase of or contracting with large telemedicine programs, which will be used to augment their existing wellness, disease management, and population health programs.