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1、Healthcare PracticeWhat to expect in US healthcare in 2023 and beyondRecent developments have complicated the outlook for industry profit pools.By Neha Patel and Shubham SinghalJanuary 2023 Raken/Getty ImagesGoing forward,a number of factors will likely influence shifts in profit pools.These include
2、:Change in payer mix:A substantial shift toward Medicare will continue,led by growth in the over-65 population of 3 percent per year projected over the next five years and continued popularity of Medicare Advantage among seniors,as reflected in the latest Centers for Medicare&Medicaid Services(CMS)e
3、nrollment data.3 However,based on our models,Medicaid enrollment could decline by about ten million lives over five years given recent legislation that will allow states to begin eligibility redeterminations,which were paused during the federal public health emergency that was declared at the start
4、of the COVID-19 pandemic.4 Commercial segment margins in 2021 were about 200 basis points lower than 2019 levels,resulting from the return of deferred care.We expect profit pools in this segment to rebound and grow at a 15 percent CAGR as EBITDA margins will likely return to historical averages by 2
5、026.The growth will be partially offset by enrollment changes in the segment,prompted by a shift from fully-insured to self-insured businesses that could accelerate as employers facing recessionary pressure seek to cut costs.Endemic COVID-19:Since the publication of our last article,COVID-19 has mov
6、ed more and more toward an endemic stage.Based on our estimates,endemic COVID-19 could result in healthcare costs of about$200 billion annually in the United States.The majority of these costs would be When we last looked at the trajectory of the US healthcare industry in our July 2022 article,“The
7、future of US healthcare:Whats next for the industry post-COVID-19?,”we had emerging concerns about what persistent inflation could cause.1 It is now clear that inflation is not transitory and that the economic outlook has meaningfully darkened.2 These economic troubles,combined with a healthcare-wor
8、ker shortage and endemic COVID-19,are clouding the industry outlook.Below,we update how these changes could affect payers,providers,healthcare services and technology(HST),and pharmacy services.Based on updated and expanded projections,we estimate that healthcare profit pools will grow at a 4 percen
9、t CAGR from$654 billion in 2021 to$790 billion in 2026;in our previous article,we estimated a 6 percent growth from 2021 to 2025.The industry faces difficult conditions in 2023,primarily because of continuing high inflation rates and labor shortages.However,we expect improvement efforts to help the
10、industry overcome these challenges in 2024 and beyond.Several segments can expect higher growth:Medicare Advantage within payers;care settings such as ambulatory surgery centers within providers;software and platforms(for example,patient engagement and clinical decision support)within HST and specia
11、lty pharmacy within pharmacy services.These assessments generally align with our earlier articles conclusions.On the other hand,the outlook for some segments has worsened compared with our previous analysis,including general acute care and post-acute care within providers and Medicaid within payers(
12、Exhibit 1).1 ShubhamSinghalandNehaPatel,“ThefutureofUShealthcare:Whatsnextfortheindustrypost-COVID-19,”McKinsey,July19,2022.2 AddieFleronandShubhamSinghal,“Thegatheringstorm:TheuncertainfutureofUShealthcare,”McKinsey,September16,2022.3“Moodysanalyticspopulationprojections,”MoodysInvestorsService,Dec
13、ember2022;MedicareAdvantagepenetrationwasincreasing bylessthan2percentannuallyfrom2016to2019butincreasedbyabout3percentannuallyin2020and2021forfurtherinformation,see“Medicareadvantage/partDcontractandenrollmentdata,”CentersforMedicareandMedicaidServices,USGovernment.4 MeghanaAmmulaandJenniferTolbert
14、,“10thingstoknowabouttheunwindingoftheMedicaidContinuousEnrollmentrequirement,”KaiserFamilyFoundation,December8,2022.The industry faces difficult conditions in 2023.2What to expect in US healthcare in 2023 and beyondoffset by lower-than-expected commercial margins with the return of deferred care.Al
15、so,we previously forecasted a 9 percent CAGR in 2021 to 2025 payer profit pools.In our updated and expanded estimates,this profit pool is expected to grow faster at an 11 percent CAGR from 2021 through an additional year to 2026,reaching$75 billion in the latter year.This is underpinned by inflation
16、-driven incremental related to the prevention and treatment of COVID-19 cases as well as long COVID.5 In July 2022,we estimated 2021 payer profit pools to be$40 billion,however,actual 2021 profit pools were$5 billion higher.Higher Medicaid EBITDA margins due to the extended public health emergency a
17、ccounted for the majority of the increase,although it was partially Web 2022Profit Pools 202126Exhibit 1 of 6Profit pools for commercial and Medicare Advantage segments,physician offices,healthcare services and technology,and specialty pharmacy segments are predicted to grow the fastest post-COVID-1
18、9.FBS:fixed-benefit and supplemental;PBM:pharmacy benefit manager;PBA:pharmacy benefit administrator.Source:McKinsey Profit Pools ModelDistribution of projected healthcare EBITDA across healthcare segments,2026,$bn202126 growth rates,%1075Payer358Provider81Servicesandtechnology65Pharmacyservices211M
19、anufacturersGroupHospitalsLogistics andsupply chainCore adminservicesData analyticsSoftwareandplatformsPaymentservicesClinicalservicesBrokersolutionsPharmacy and biotechnologyConsultingPBM/PBASpe-cialtyphar-macy/infusionDistri-butorsDispen-sersMedical productsOther professionalsPre-acute/non-acuteOf
20、fice-based physiciansDiagnosticPost-acuteIndividualMedicaidFBSMedicareAncillaryVirtual healthcareExhibit1 5 Therangeis$137billionto$379billion,basedonscenarioanalysisfromMcKinseysCOVID-19EpidemiologicalScenarioPlanningTool.Theanalysisincludesarangeof110millionto220millionannualcases,ofwhich10to15per
21、centrequireoutpatienttreatment;4,100to6,100perdayrequireanon-intensivecareunit(ICU)hospitaladmission;and400to900perdayrequireanICUadmission.ThecostofCOVID-19treatmentisobtainedfromBlueCrossBlueShieldandFairHealth;long-COVIDtreatmentcostsarebasedontheestimatethat3percentofcasesresultinlongCOVID(UKOff
22、iceforNationalStatistics)forthreeto12months;publishedestimatesoflong-COVIDsymptoms(UpToDate);andstandardtreatmentcostsforthosesymptoms(MedicalExpenditurePanelSurvey).Theupper-boundestimatesoflong-COVIDincidentsassumeabout20millionUSlong-COVIDcasesperyear(USCensusBureausJulyAugust2022HouseholdPulseSu
23、rvey).Despite substantial uncertainty in ascertaining the prevalence and resulting cost impact of long COVID,our aggregate analysis,using these enumerateddatasources,employsapointestimateof$19billionasaconservativeestimate.ForbothongoingCOVID-19andlong-COVIDtreatment,higherincidencerateswouldresulti
24、nanestimateatthehigherendoftherange.Testingandvaccineestimatesarebasedon2021costs per test and per vaccine,and data from the US Department of Health and Human Services,and the US Centers for Disease Control and Preventionforannualdemandfortestingandboosters.Forthisfactor,higherutilizationoftesting(t
25、imesperpersonperyear)wouldresultinanestimateatthehigherendoftherange.Allfiguresarescaledtonominal2026estimates.3What to expect in US healthcare in 2023 and beyondas margins compressed with the return of deferred care.We expect the commercial segments EBITDA margins to return to historical levels by
26、2026,and profit pools to reach$21 billion,growing at a 15 percent CAGR from 2021 to 2026.Within this segment,a shift from fully-insured to self-insured business will likely accelerate as recessionary pressures prompt employers to cut costs.The fully-insured group enrollment could drop by 150 basis p
27、oints annually from 2021 to 2026,and self-insured increase by 100 basis points annually during the same period.We expect increased labor costs and administrative expenses to reduce payer EBITDA by about 60 basis points in 2022 and 2023 combined.In addition,providers premium rate increases and accele
28、rated Medicare Advantage penetration.Nonetheless,we expect that growth will be slower than normal between 2022 and 2023 due to inflationary pressure and provider reimbursement rate increases,both in-year margin pressures(Exhibit 2).Based on our revised estimates,the mix of payer profit pools will sh
29、ift further toward the government segment.Overall,the estimated profit pools for this segment are expected to be about 50 percent greater than the commercial segment by 2026($33 billion compared with$21 billion)as Medicare Advantage penetration is expected to reach 52 percent in 2026.Profit pools fo
30、r the commercial segment declined from$18 billion in 2019 to$11 billion in 2021 Web 2022Profit Pools 202126Exhibit 2 of 6By 2026,estimated profit pools for government segments will be about 50 percent larger than commercial segments driven by accelerated Medicare Advantage penetration.Figures exclud
31、e investment income.AD&D:accidental death and dismemberment;ASO:administrative services only;MA-PD:Medicare Advantage prescription drug plan;PDP:prescription drug plan.Excluding losses from long-term care insurance;total profit in fixed-benefit and supplemental products is$11.4 billion;the width of
32、the vertical represents this amount.Source:McKinsey Profit Pools ModelDistribution of projected healthcare EBITDA across payer segments,2026,$bn21Group9Individual33Government7Ancillary5Fixed-benefitandsupplementalLarge groupIndividualDentalVisionHospital indemnityLong-term disabilityMedicaidAccident
33、/AD&DLong-term careShort-termdisabilityCritical illnessMedicare Advantage and MA-PDPDPMedicare supplementStop lossASOSmall goup202126 growth rates,%10Exhibit24What to expect in US healthcare in 2023 and beyondProvider profit pools grew from$273 billion in 2019 to$314 billion in 2021,a 7 percent CAGR
34、.Growth in 2021 resulted from making up for care deferred from the first year of the COVID-19 pandemic as well as additional healthcare demand attributable to COVID-19.Provider profit pools faced substantial pressure in 2022 and are likely to continue to do so in 2023 as a result of inflation and in
35、creased labor costs.We now estimate that total EBITDA will fall by 25 percent from 2021 to 2023,declining to$235 billion.We then forecast a rebound,with 15 percent annual growth from 2023 to 2026,or total EBITDA of$358 billion by 2026(estimates now include 2026 as an additional projected year).will
36、push for reimbursement rate increases(up to about 350 to 400 basis-point incremental rate increases from 2023 to 2026 for the commercial segment and about 200 to 250 basis points for the government segment),according to McKinsey analysis and interviews with external experts.6In July 2022,we estimate
37、d that provider profit pools would grow at a 7 percent CAGR from 2021 to 2025.We now forecast a 3 percent CAGR from 2021 to 2026 in our updated and expanded estimates,with the decline primarily due to increased costs owing to high inflation and labor shortages(Exhibit 3).Web 2022Profit Pools 202126E
38、xhibit 3 of 6Most provider segments will grow less than 5 percent CAGR from 2021 to 2026 due to cost increases.ALF:assisted living facilities;BH:behavioral health;FSED:freestanding emergency department;Hospice includes palliative care centers;IRF:inpatient rehabilitation facilities;LTAC:long-term ac
39、ute care hospitals;OP:outpatient;VBC:value-based care.Note:EBITDA and CAGR based on growth in nominal dollar margins.Source:McKinsey Profit Pools ModelDistribution of projected healthcare EBITDA across provider segments,2026,$bn143Hospitals58Office-basedphysicians14 Diag-nostic53Post-acutecare41Pre-
40、acute/non-acute4Virtual healthcare44OtherprofessionalsGeneral acute careDentistsAmbulanceChiropractorsDialysisclinicsPrimary carephysiciansVBC staff modelSpecialist physiciansUrgent carecentersAmbulatorysurgerycentersOP behavi-oral healthHome healthIndependent labsImagingcentersALFHospiceOP rehabili
41、tation facilitiesResidential BHIRFSkilled nursingfacilitiesPsychiatricOfficevisitsUrgentcareAFSEDBERetail clinicsCOnsiteclinicsDLTACEBDCHome healthA202126 growth rates,%10Exhibit36 Forfurtherinformationonthegovernmentsegment,see“MedicarePaymentAdvisoryCommissionpublicmeeting,”MedicarePaymentAdvisory
42、Commission,December8,2022.5What to expect in US healthcare in 2023 and beyondacute care profit pools could be severely affected by labor shortages(particularly nurses),other sites of care(such as ambulatory surgery centers)and virtual care should continue to grow.We also anticipate an accelerated ad
43、option of value-based care as stakeholders,including a broader set of providers and payers,aim for enhanced care management and effective cost We anticipate that providers will seek reimbursement increases of about 350 basis points from 2023 to 2026(above set rate increases).There are three potentia
44、l scenarios that providers may face for EBITDA recovery(Exhibit 4).Within this overall negative outlook for providers,there are meaningful exceptions.Although post-Other factors include change in provider share mix and service mix.Source:McKinsey Profit Pools ModelProviders may face three potential
45、scenarios for EBITDA recovery.McKinsey&Company2021 EBITDAExcess cost inflationCoverage shiftsCost optimizationIncremental rate increaseOther2026 EBITDABest scenario0246810122021 EBITDAExcess cost inflationCoverage shiftsCost optimizationIncremental rate increaseOther2026 EBITDAMiddle scenario0246810
46、122021 EBITDAExcess cost inflationCoverage shiftsCost optimizationIncremental rate increaseOther2026 EBITDAWorst scenario024681012Exhibit46What to expect in US healthcare in 2023 and beyondestimate to$49 billion because of wage inflation and the drag of fixed technology investment that has not achie
47、ved its full benefits yet,inclusive of an additional year projected for 2026(Exhibit 5,part 1).However,we see solid growth in the sector starting in 2023,especially as technology adoption by providers and payers continues to accelerate.We now estimate a 10 percent CAGR between 2021 and 2026,to$81 bi
48、llion by 2026.This is a one percentage-point-higher CAGR than our July estimates last year for 2021 to 2025 growth,due to greater demand from payers and providers looking to improve efficiency.That would make it the fastest-growing sector in healthcare.We see the greatest acceleration in software an
49、d platforms(for example,patient engagement and clinical decision support)as well as data and analytics,with 13 percent and 19 percent CAGRs,respectively(Exhibit 5,part 2).management through improved utilization and other measures,such as increasing the use of alternative sites of care.7We expect to
50、see continued cost optimization measures to tackle rising costs,such as increased labor productivity efforts and the application of technological innovation.In a positive best-case scenario,where the majority of hospitals and a third of post-acute players recoup substantial cost savings(350 basis po
51、ints for hospitals,250 for post-acute),industry EBITDA margins would decline by 90 basis points.In a downside worst-case scenario,where lower savings are achieved(200 basis points for hospitals,150 basis points for post-acute)for half of hospitals and a quarter of acute care players,we estimate marg
52、in deterioration of 250 basis points from a baseline of 12 percent.In July 2022,we estimated that years HST profit pools to be$53.7 billion.We have revised our Web 2022Profit Pools 202126Exhibit 5A of 6Healthcare services and technology profit pools are projected to continue positive growth from 202
53、1 to 2026,particularly in data and technology-focused segments.Healthcare services and technology.Source:McKinsey Profit Pools ModelDistribution of projected healthcare EBITDA across HST1 segments,2026,$bnProvider logistics and supply chainConsulting servicesData and analyticsSoftware,platforms,and
54、technologyCore administrative servicesPayment servicesBroker servicesClinical services202126 growth rates,%10Exhibit 5,part 17 ZahyAbou-Atme,RobAlterman,GunjanKhanna,andEdwardLevine,“Investingintheneweraofvalue-basedcare,”McKinsey,December16,2022.7What to expect in US healthcare in 2023 and beyond H
55、ealthcare services and technology.CM:care management;DM:disease management;EMO:electronic marketing organization;FMO:field marketing organization;GPO:group purchasing organization;HIE:health information exchange;MA:Medicare Advantage;PHM:population health management.Includes patient engagement,CM,DM
56、 solutions.Source:McKinsey Profit Pools ModelHealthcare services and technology profit pools are projected to continue positive growth from 2021 to 2026,particularly in data and technology-focused segments.Core administrationCore administrative servicesLogistics and supply-chain servicesSupply-chain
57、 management(GPO)Biomedical and clinical engineeringProvider facility managementWorkforce managementPayment servicesHealthcare savings/financial accountsPayment integrity and subrogation servicesRevenue cycle managementRisk adjustment/revenue managementConsumer paymentsMedical financingClinical servi
58、cesUtilization managementPatient and member engagementSpecialty carve-out management servicesProvider enablementNetwork management servicesPHM/CM/DMHealth and wellness administrationPatient advocacyBroker solutionsCommercial broker,small(10Exhibit 5,part 28What to expect in US healthcare in 2023 and
59、 beyondCAGR from 2021 to 2025.Our updated estimates found that this growth rate will remain the same from 2021 through an additional year of 2026,with profit pools reaching$65 billion by 2026 from$55 billion in 2021.The growth is largely due to continued utilization of drugs and higher prices for sp
60、ecialty drugs but will be partially offset by reimbursement pressure,reduced profit margins,and the growth of specialty generics and biosimilars(Exhibit 6).Specialty pharmacy profit pools are expected to increase at a 7 percent CAGR from 2021 to Three factors account for the anticipated faster growt
61、h in HST.First,we expect higher demand from payers and providers to improve efficiency and address labor challenges.Second,payers and providers are likely to be willing to absorb vendor price increases where there is clear value.Third,we expect HST companies to make operational changes that will imp
62、rove efficiency,including through the use of technology and automation across services.In July 2022,we estimated that pharmacy services profit pools would grow at a 3 percent Web 2022Profit Pools 202126Exhibit 6 of 6Pharmacy services will continue to see benefits from the growth of specialty pharmac
63、y.Excludes profit earned by PBM-owned specialty pharmacies and mail pharmacies,which is captured under central fill specialty pharmacy and mail respectively.Excludes specialty pharmacy(specialty dispensed through retail channels is captured under retail-based specialty pharmacy).Source:McKinsey Prof
64、it Pools ModelDistribution of projected healthcare EBITDA across the pharmacy value chain,2026,$bn11Pharmacy benefit manager/administrator(PBM/PBA)33Specialty pharmacy and infusion services10Distributor/wholesaler10TraditionaldispensersPBM/PBA non-dispensingHospital outpatient infusionPharmaceutical
65、 distributors/wholesalersRetailMailPhysician office/ambulatory site infusionHome infusionCentral fill specialty pharmacyHospital-owned specialty pharmacyRetail-based specialty pharmacy202126 growth rates,%10Exhibit6We expect accelerated improvement efforts to help the industry address these challeng
66、es in 2024 and beyond.9What to expect in US healthcare in 2023 and beyondoffered higher wages and benefits,while others limited pharmacy operating hours,closed,or optimized their store footprint.9 Some larger players are investing in additional technology enablement,like micro-fulfillment centers an
67、d robotics,to expand capacity and lower dispensing costs over the next few years.10 In future,investment in technology and automation will continue to reshape the pharmacy industry as well as increase the role of pharmacists in delivering services and clinical guidance to patients.The US healthcare
68、industry faces demanding conditions in 2023,including recessionary pressure,continuing high inflation rates,labor shortages,and endemic COVID-19.But players are not standing still.We expect accelerated improvement efforts to help the industry address these challenges in 2024 and beyond,leading to an
69、 eventual return to historical average profit margins.2026,a lower rate than our previous 2021 to 2025 estimate;contract pharmacy pressures in particular have affected margins across this segment.Physician office and ambulatory infusions have outpaced initial growth estimates,with the overall market
70、 expected to grow at an 11 percent CAGR from 2021 to 2026 compared to the overall infusion-market growth rate of 9 percent for the same period.Retail dispenser profit pools are expected to fall due to reimbursement pressures and margin contraction;this is in addition to challenges they face from red
71、uctions in COVID-19 vaccine administration and testing(retail pharmacies administered about 200 million vaccines in 2021 compared to about 85 million in 2022).8In addition,the pharmacy services sector continued to face worker shortages and inflationary pressures throughout 2022.These challenges affe
72、cted dispensers across channelsfor example,traditional retail dispensers,and retail-based specialty and provider-based pharmacies.Many of them Neha Patel isapartnerinMcKinseysNewYorkofficeandShubham Singhal is a senior partner in the Detroit office.TheauthorswishtothankShahedAl-Haque,ClaudiaCastelin
73、o,ZacharyGreenberg,ScottHeim,AnkitJain,AlokLadsariya,SiddharthManot,MuraliPothupalem,andLaraSanfilippofortheircontributionstothisarticle.8 “ThefederalretailpharmacyprogramforCOVID-19vaccinations,”CentersforDiseaseControlandPrevention,2022;AdamFein,The 2022 economic report on US pharmacies and pharma
74、cy benefit managers,DrugChannelsInstitute,March2022.9“Survey:Three-quartersofcommunitypharmaciesreportstaffshortages,”NationalCommunityofPharmacistsAssociation,August11,2022;“WalgreensBootsAllianceInc.Q42022earningscalltranscript,”SeekingAlpha,October13,2022;“CVSHealthQ32022earningscalltranscript,”T
75、heMotleyFool,November2,2022;“RiteAid(RAD)Q32023earningscalltranscript,”TheMotleyFool,December21,2022.10“WalgreensBootsAlliance,Inc.(WBA)Q42022earningscalltranscript.”SeekingAlpha,October14,2022;TomWilliams,“CVStriesoutremotesystemtohelpfillprescription,”Wall Street Journal,December 5,2022.10What to expect in US healthcare in 2023 and beyond