http://www.healthcarefinancenews.com/sponsored/advanced-analytics-triple-win-payers

Virtually every organization working in healthcare – payers, hospitals, physicians, and employer group health plans – must do more with fewer resources. That’s especially true for payers.

The Affordable Care Act may have created what Gartner Research estimates to be a $33 billion opportunity for payers in the form of new individual customers, but it also generated new demands. For starters, payers are now held to a higher standard for administrative spend. The ACA’s Medical Loss Ratio (MLR) provisions require payers to spend at least 80 percent and 85 percent of premium dollars, for individuals/small groups and large employer group health plans respectively, on medical care and quality activities or issue a rebate to customers. As intended, this limits profits, salaries and broker commissions and administrative spend on business activities such as customer service, network and product development, and information technology.

In many markets, premium pressures have increased. As the result of the ACA and healthcare exchanges, there is a much higher level of transparency about individual and small group premiums, often leading to price competition. Large employer group health plans too have more options, including contracting directly with provider groups, all of which translates to premium challenges for most payers.