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1、The 2023 EY-Parthenon and KLAS Research Payer Tech Study2The 2023 EY-Parthenon and KLAS Research Payer Tech Study|The 2023 EY-Parthenon and KLAS Research Payer Tech Study highlights Cost optimization is the top strategic priority for 70%of health insurance payers as their profits face pressure from
2、deferred patient activity,increasing competition and an ever-changing regulatory landscape;driving growth via growing market share and business diversification were also noted as key strategic priorities.Payers plan to increase their member centricity using a combination of tech and services,while a
3、lso leveraging their health care IT(HCIT)solutions to optimize medical and administrative costs,comply with shifting regulatory requirements and diversify revenue streams.HCIT solutions with a through line to revenue and costs are expected to see increased investment;45%of payers expect risk adjustm
4、ent,condition management and payment integrity solutions to be“highly significant”areas of investment.Third-party vendors are an integral part of these operations currently,with 80%of payers outsourcing a portion or all of their workflows across functions.Occasional insourcing,typically for larger p
5、ayers,points to increasing sophistication on in-house capabilities,which payers intend to leverage to pursue avenues for revenue diversification.Interoperability,reporting analytics and ease of use are top-of-mind vendor selection criteria in the current state.Payers are cautiously optimistic about
6、adopting differentiated generative AI(GenAI)capabilities within their HCIT solutions in the next two years.HCIT vendors need to showcase reliable,traceable outcomes simply having artificial intelligence(AI)and machine learning(ML)capabilities is not going to impress potential clients.IntroductionEvo
7、lving payer HCIT investment trendsHealth care payers face many challenges that are shaping strategic priorities from cost containment to IT spending to member engagement.They have experienced higher than expected medical costs over the last two years,driven by rising demand for health care services
8、that were deferred during the COVID-19 pandemic.Commercial payers see their business model affected as an increasing number of employers move to a self-funded model.Meanwhile,increased health care utilization has been a double whammy for Medicare payers,as the Center for Medicare and Medicaid Servic
9、es(CMS)announced a lower rate increase compared to prior years(3%in 2024 vs.5%in the prior three years).Likewise,Managed Medicaid plans face about a 15 million drop in member enrollment with the end of the redetermination waiver period.At the same time,payer business models are being disrupted by pr
10、ovider incumbents that are taking on risk and typical payer responsibilities,as well as new entrants and partnerships,particularly from large corporations that are making significant forays into health care.Combined,these macroeconomic forces and industry trends are putting pressures on payer margin
11、s,forcing them to re-evaluate their cost models and growth options.With these trends in mind,EY-Parthenon professionals and KLAS Research interviewed and surveyed executives across a diverse mix of payer types,sizes and line of business(LoB)coverage to understand their overall strategic priorities,t
12、he impact on spend for HCIT solutions and the future outlook for specific subsegments of solutions.The insights may help answer the following questions for a variety of players in the health care ecosystem.Investors:What are the key trends in payer HCIT?Which areas are ripe for increased investment?
13、What are key investment considerations in the payer tech and tech-enabled services market?HCIT vendors:What do payers want from their HCIT vendors?How do payers make decisions?What could be potential solutions to cross-sell(or not)?Payers:How are your competitors dealing with market forces?Where are
14、 your competitors making investments?How can you up your HCIT game?3The 2023 EY-Parthenon and KLAS Research Payer Tech Study|What are payers strategic priorities?14The 2023 EY-Parthenon and KLAS Research Payer Tech Study|Given the economic backdrop,it is no surprise that 72%of payers say cost optimi
15、zation is a top-three strategic goal(see Figure 1.1).Payers are focused on managing both medical and administrative costs(see Figure 1.2).Smaller payers in particular need to focus on this,given their relatively limited resources to manage utilization and weather margin erosion compared to larger pa
16、yers.Larger payers,with richer coffers,have the means to weather a bad year and juggle growing both the bottom and top lines,with the latter coming through expansion across markets or products.Neither goal is achievable though without engaging the member.While cost optimization is not a novel goal,s
17、trategies to achieve this have evolved over time across both the medical and pharmacy spend.Traditional levers(e.g.,prior authorizations,quantity limits),as well as newer techniques(e.g.,personalized care plans),are most effective if payers can engage members,thus making engagement the No.1 priority
18、.Similarly,ensuring retention and growth in the member base relies on payers ability to satisfy existing members and win over new ones.Payers are investing in improving the overall experience for members by going beyond customer support resources for benefits and billing to offer advocacy around the
19、 right care pathways,price transparency,wellness engagement,and mental or behavioral health support.Figure 1.1Top strategic vision goals over the next two years Section 1|What are payers strategic priorities?ExpandLoBsIncreasemarket share geographicexpansion1 Primary goal2 Secondary goal3 Tertiary g
20、oal“Which of the following are elements of your organizations strategic vision over the next two years?Please rank up to three options.”BusinessmodeldiversificationIncreasemarket share acquisitionCostoptimizationVerticalintegration007080Source:EY-Parthenon payer survey(n=102).n=73n=57n=46
21、n=42n=38n=305The 2023 EY-Parthenon and KLAS Research Payer Tech Study|Further,in the face of mounting pressure on their business model from multiple sides,payers are examining various avenues for revenue growth and diversification.Depending on the payers size,expansion efforts vary as the payer size
22、 increases,the priority shifts from LoB expansion to business model expansion to expansion across the value chain.Expansion to new markets or additional LoBs is critical for smaller payers,which need scale and an increased footprint of covered lives to compete.While key priorities and the strategies
23、 to achieve these may vary among payers,the common thread is the need for improved,efficient resources with a particular emphasis on HCIT solutions.1 The following includes a description for the strategic priorities listed in Figure 1.2 in more detail.(1)Improve member or patient experience improvin
24、g member experience through streamlining care navigation,improving customer support for billing and benefit navigation,and providing access to timely and effective care strategies to help improve care quality.(2)Grow membership base increasing the number of members enrolled in the payers health plan
25、s.(3)Optimize care models and associated medical spend reducing care inefficiencies by improving access to care and the quality of services provided to minimize the spend on preventable expensive and long-term medical issues.(4)Optimize overhead and administrative costs improving workflow efficienci
26、es,optimizing internal staffing needs and improving capital allocation.(5)Optimize revenue capture per member aligning the reimbursement per enrolled member to be commensurate with their health status and risk profile.(6)Increase adoption of value-based care(VBC)models across network motivating prov
27、iders contracting with the payer to engage in risk-based member management and a transition away from fee-for-service billing.Figure 1.2Top priorities over the next two yearsPlease see footnote for definitions in Figure 1.2.1 Section 1|What are payers strategic priorities?02550?Improve member/patien
28、t experienceOptimize revenue capture per membern=50n=49n=42n=32n=31n=29Growmembershipbase1 Primary priority2 Secondary priority3 Tertiary priority“What are your organizations most significant strategic priorities over the next two years?Please rank up to three options.”Optimize care models and assoc
29、iated medical spendIncreaseadoption ofVBC models across networkOptimize overhead and administrationcostsSource:EY-Parthenon payer survey(n=102).6The 2023 EY-Parthenon and KLAS Research Payer Tech Study|How are shifting strategic priorities affecting HCIT investment and spend?27The 2023 EY-Parthenon
30、and KLAS Research Payer Tech Study|0%20%40%60%80%100%Future HCIT spendSource:KLAS Research interviews;EY-Parthenon analysis.?“How do you expect your organi-zations HCIT spending to change over the next 12-24 months?”n=21N/A responses were excluded from the analysis.Payers expect to increase overall
31、spending on HCIT by 3%to 5%in the next two years(see Figure 2.1).Spending on third-party HCIT vendors is expected to be even higher.While there is some variation in magnitude,payers across sizes and LoBs have an appetite for an increase in near-term HCIT spending(see Figure 2.2).Figure 2.1Future HCI
32、T spend expectation among payersFigure 2.2HCIT investment priority by payer type and by LoBSignificantly increaseIncreaseStay the sameDecrease Significantly decreaseFully insuredMedicareMedicaidSelf-insured%6/768%56%54%45%Source:EY-Parthenon payer survey(n=102).n=31n=16n=13n=31?“Overall,how signific
33、ant an investment priority is health care IT(HCIT)over the next two years for your organization?Please answer on a scale of 1 to 7,where 1=Not at all significant and 7=Highly significant.”0%20%40%60%80%100%Section 2|How are shifting priorities affecting HCIT investment and spend?A key for us will be
34、 streamlining our processes using both technology and AI to help drive our automation.That is one of our priorities because we have fallen behind on it.We still have a lot of manual report deliveries,manual processes,and manual validation tools.We want to decrease our application stack,and automatio
35、n is a driver of that.Chief technology officer,provider-sponsored health plan“7=Highly significant1=Not at all significant2 3 4 5 6 8The 2023 EY-Parthenon and KLAS Research Payer Tech Study|One of our analytics teams big priorities is to get better at the speed and quantity of how were evaluating th
36、e actions that were taking as a company to decrease medical costs,improve quality and increase revenue.Were trying to get better at systematically measuring that.Chief technology officer“Section 2|How are shifting priorities affecting HCIT investment and spend?The trends affecting spending on HCIT s
37、olutions are driven by a combination of:1.Optimizing administrative costs to diminish reliance on manual labor resources and increasing overall efficiency.2.Focusing on medical and pharmacy cost containment solutions with clearly demonstrable return on investment(ROI).3.Complying with regulatory cha
38、nges for Medicare Advantage Organizations(MAOs)in particular,recent changes by CMS that focused on interoperability,prior authorization and risk adjustment have spurred a ramp up in investment in platforms that support maintaining operational compliance with CMS requirements.4.Go-to-market strategie
39、s with diversified business models(largely applicable to national and large regionals).While the overall spending on HCIT is expected to rise,payers view this as a necessary investment to manage and optimize their operations.Harnessing enhanced comprehensive data sets(e.g.,360-degree view of members
40、 data across demographic,clinical and socioeconomic factors)and using leading-edge technology(e.g.,automation,AI)will pave the path to significant reductions in the medical and administrative spend.Figure 2.3Top drivers of HCIT spending?Integratecutting-edge technologyReduce workforce burdenIncrease
41、d demand for patient/member enablementRegulatory complianceInvest in better HCIT solutionsIncreased demand for provider enablementPaymentmodelchangesIncreasedprice of HCIT solutionsIncreasedHCIT budgetReduced focus on investmentin other areasn=50n=45n=29n=28n=24n=22n=21n=19n=18n=91 Primary driver2 S
42、econdary driver3 Tertiary driver“What are key drivers for increasing health care IT(HCIT)spending in the future?Please rank up to three options.”Source:EY-Parthenon payer survey(n=102).0554045509The 2023 EY-Parthenon and KLAS Research Payer Tech Study|9The 2023 EY-Parthenon and KLAS Resea
43、rch Payer Tech Study|What does investment look like in the current HCIT landscape?310The 2023 EY-Parthenon and KLAS Research Payer Tech Study|Payer HCIT solutions can broadly be categorized2 as shown below.Please note:Examples of vendors are not intended to be comprehensive.Key areas of the payer sp
44、end are aligned with the overall strategic initiatives.51%of payers say member engagement is a substantially significant area of investment(see Figure 3.1).3 Payers are also strategically leveraging tech to implement margin optimization measures.By automating processes like prior authorization and s
45、treamlining internal system interoperability(e.g.,enhanced integration between core administrative processing solutions(CAPS)and provider network solutions),payers are making efficiency gains that reduce administrative costs and improve the administrative loss ratio(ALR).4 On the medical loss ratio(
46、MLR)5 front,payers across all LoBs note that solutions that directly reduce and control the medical spend are the highest priority over the next two years namely payment integrity,condition management and utilization management.MAOs in particular expect to double down on prospective risk adjustment
47、solutions that are closer to the point of care given CMS increased scrutiny of these processes.Overview of HCIT solution ecosystemSource:EY-Parthenon interviews and analysis;EY-Parthenon payer survey(n=102).SegmentBenefits,billing and claims managementCore administrative processing solutions(CAPS)Pa
48、yment integrity and cost containmentNetworkmanagementand optimizationContract and performance trackingProvider engagement and management solutionsCostcontainmentsolutionsMember-focusedsolutionsSubsegmentExample vendorsInteroperabilityUtilization managementCase+disease+condition managementPopulation
49、health managementRisk and quality managementMemberengagementHealth equityWellness benefits TriZetto,Pega,Conduent,HealthEdge Cotiviti,MultiPlan,Zelis,Equian,Elap,Optum Edifecs,Clarify Health Edifecs,1upHealth,Epic Medecision,Omada Health,TriZetto Livongo,Omada Health Arcadia,Enli Health Intelligence
50、,Health Catalyst,Lightbeam Apixio,Episource,Avantmed,Inovalon Unite Us,NowPow Sleepio,Noom,Headspace SCIO Health Analytics,Ability Network,Envolve Pharmacy Solutions Virgin Pulse,Sharecare,Castlight Health Inc.,Rally HealthDefinitionSolutions used to support network administration,implement infrastr
51、uc-ture,and manage and optimize provider contractsSolutions used to create benefits,configure plans and guide customers through enrollment journey;also,used to streamline billing administration and claims processing operationsSolutions used to finalize claims via catching errors and fraudulent codin
52、g by matching with national and payer guidelines Solutions used to support carriers in entering into value-based engagement with providers and vendors(e.g.,VBC opportunity identifica-tion,contract modeling,performance analysis,payment calculations)Solutions that support interoperability both across
53、systems within a payer,as well as between payer and provider systems(e.g.,the sharing of health record information)Solutions used to review clinical services to ensure medical necessity,as well as manage associated costs through optimization of care services utilized,site of care,etc.(inclusive of p
54、rior authorization programs)Solutions used to holistically treat patients,across all medical and behavioral conditions,taking into account their needs covered by the totality of medical,pharmacy and wellness benefitsSolutions used to take a holistic,proactive approach to stratifying the carrier popu
55、lation stratification to catering care solutions appropriate to each resulting cohortSolutions used to aid payers in retrospective or prospective risk adjust-ment,identifying care gaps and supporting quality reporting Solutions used to engage the member through their clinical journeySolutions used t
56、o deliver ancillary employee assistance programsand health and wellness benefits to members through digital platforms Solutions used to 1)support equitable access to care across all members within the carrier portfolio and in its region of operation;and 2)at a member level,support the member with ac
57、cess to health and Social Determinants of Health(SDoH)factors2 Categorization is based on EY-Parthenon analyses of HCIT vendors;categorization and measurement of vendors according to KLAS Research can be found on .3 Substantially significant includes responses for 6 and 7;respondents answered on a s
58、cale of 1 to 7,where 1=Not at all significant and 7=Highly significant.4 The administrative loss ratio(ALR)is the percentage of premium dollars that a health plan spends on administrative costs and processing claims.5 The medical loss ratio(MLR)is the percentage of premium dollars that a health plan
59、 spends on medical claims and quality improvements.Section 3|What does investment look like in the current HCIT landscape?11The 2023 EY-Parthenon and KLAS Research Payer Tech Study|Lower new investments are seen in areas with either high maturity and solution stickiness(e.g.,CAPS),or where there is
60、a less provable return on investment(ROI)(e.g.,wellness benefits).Payers also expect to see a significant increase in investments in interoperability and health equity solutions,largely driven by current immaturity in these areas.These solutions have newfound momentum and more runway for future grow
61、th compared to mature solutions.Figure 3.1Significance of HCIT investment by solution type“Payment integrity is an area that we will have expanding focus on.Its a priority for us because we want to recover funds that were paid inappropriately,ensure the safety of our members,and make sure our member
62、s are receiving the highest quality care possible.Chief medical officer,regional Blues Section 3|What does investment look like in the current HCIT landscape?Source:EY-Parthenon payer survey(n=102).“Moving forward,how significant of an investment priority are the following health care IT(HCIT)catego
63、ries over the next two years?Please answer on a scale of 1 to 7 where 1=Not at all significant and7=Highly significant.”%6/751%47%42%40%39%39%38%37%33%29%29%28%0%20%40%60%80%100%Benefits,billing,and claims managementCost containment solutionsMember focused solutionsn=102n=102n=102n=102n=102n=102n=10
64、2n=102n=102n=102n=102n=102Member engagementPayment integrity and cost containmentCase+disease+condition managementRisk and quality managementPopulation health managementContract and performance trackingNetwork management and optimizationHealth equityInteroper-abilityCAPSWellness benefitsUtilization
65、managementProvider engagementand managementfocused solutions?1=“Not at all significant”7=“Highly significant”12The 2023 EY-Parthenon and KLAS Research Payer Tech Study|How do payers leverage internal and external resources?413The 2023 EY-Parthenon and KLAS Research Payer Tech Study|Most payers,80%in
66、 the survey,outsource some portion of their operations to a third-party vendor,though the level and type of outsourcing may vary(see Figure 4.1).For operations with strong revenue,regulatory or compliance linkages(e.g.,payment integrity,risk adjustment),vendors typically play the role of a“second ch
67、eck.”Across payer types,nationals(including large Blues)and new age tech-oriented payers indicated the higher likelihood of managing operations in-house(30%).While larger payers use insourcing to gain a scale of economies,tech-oriented payers claim to have built their value proposition centered arou
68、nd operational efficiencies to be gained from using their proprietary tech stack.Given the resource and capital intensity,these payers are unlikely to adopt third-party HCIT vendors for core processes.However,they do note using third-party support for operations outside their core value proposition,
69、typically clinically focused functions.The propensity to leverage in-house vs.outsourced vendors varies by LoB(see Figure 4.2).As an example,given the recent CMS final notice,it is no surprise that payers in the Medicare LoB are relying on external support for risk and quality management processes.S
70、imilarly,given the transient nature of the Medicaid member population,payers in the Medicaid LoB could use support with member engagement.Figure 4.1Management strategy by solution typePartially outsource to a third-party vendorFully outsource to a third-party vendorIn-house using homegrown tech solu
71、tionsIn-house using mostly manual operations?Benefits,billing and claims managementProvider engagement and managementCost containmentMember focused 0%20%40%60%80%100%Network manage-ment and optimiza-tionContract and perfor-mance trackingInteroper-abilityUtilization manage-mentCase+disease+condition
72、manage-mentPopulation health manage-mentRisk and quality manage-mentMember engage-mentHealth equityWellness benefitsCAPSPayment integrity and cost contain-ment“Please select the option that best describes how your organization predominantly manages key operations for each of the following categories
73、.If multiple options are utilized,select the one that is used most commonly.”N/A16%27%29%16%19%20%29%26%22%26%16%managedinternally68%42%31%18%47%44%28%29%36%29%19%16%6/7 verydifficult to switchN/A organization does not utilize this operation and it is excluded from analysis.Source:EY-Parthenon payer
74、 survey(n=102).Section 4|How do payers leverage internal and external resources?14The 2023 EY-Parthenon and KLAS Research Payer Tech Study|This variation in the propensity to adopt third-party vendors by type of payer and LoB should provide guidance for leadership at these HCIT vendors,as well as fo
75、r the investors finding opportunities around these areas for future growth.Few solution types are expected to see a significant shift in the vendor count over the next two years.Vendor relationships tend to be somewhat sticky,making it difficult to replace or remove existing vendors across functions
76、.Most payers are actively planning continued investments in the form of solution replacement,upgrades or add-ons without a change in the overall number of vendors,except where additional vendors can yield incremental gains,such as in risk adjustment and member engagement.A small portion of payers ha
77、ve also brought previously outsourced HCIT functions in-house,though this remains relatively uncommon.For payers that do make this shift,there is potential to diversify revenue streams by selling these solutions to other payers with appropriate remodeling and repackaging of the solution.Despite the
78、expressed reservations around HCIT solutions owned by the competition,40%of payers currently rely on tech solutions from other payers.This is likely largely skewed by UHGs widely utilized Optum and Change health care offerings;among the Blues,it is not uncommon to see plans opt to use products or se
79、rvices developed by fellow Blues plans.Figure 4.2Insourcing vs.outsourcing management strategy by solution type“We partner with a solution developed by another large Blues plan for all of our systems and technology.That is an ongoing strategic initiative,and the engine handles everything on our plat
80、form from processing claims and working telephones to helping us launch new,imperative strategic initiatives.VP,regional Blues“Please select the option that best describes how your organization predominantly manages key operations foreach of the following categories.If multiple options are utilized,
81、select the one that is used most commonly.”?Most likely to manage in-houseBenefits,billing and claims managementPayment integrity and cost contain-mentNetwork manage-ment and optimizationInteropera-bilityUtilization manage-mentCase+disease+condition manage-mentPopulation health manage-mentRisk and q
82、uality manage-mentHealth equityWellness benefitsCommercialEqual across all LoBsMedicaidMedicareCommercialMedicare/MedicaidMedicareMedicaidCommercial Medicare/MedicaidMedicaidProvider engagement and management solutionsCost containment solutionsMember-focused solutionsMember engage-mentMedicareEqual
83、across all LoBsCommercialMedicaidMedicareCommercial CommercialMedicareMedicaidCommer-cialCommer-cialMost likely to outsourceContract andperformancetrackingLowHighLevel of insourcingLowHighLevel of outsourcing Section 4|How do payers leverage internal and external resources?15The 2023 EY-Parthenon an
84、d KLAS Research Payer Tech Study|How do payers select HCIT solutions?516The 2023 EY-Parthenon and KLAS Research Payer Tech Study|We start making those decisions in terms of what tools available,whats best,what integrates well with within our platforms,so we can continue that automation process and t
85、hen also build on top of it.“Chief information officer,payer organizationFigure 5.1Decision-making criteriaWhen evaluating HCIT vendors,payers are focused on the following attributes:internal and external interoperability,price,reporting analytics and ease of use.Interoperability,particularly with i
86、nternal payer systems,is the most significant payer consideration,with 80%of payers noting substantial significance.6 Given the current focus on costs,price is also another important factor.In one-on-one interviews,industry executives noted cybersecurity as an emerging factor.The breadth of function
87、ality and the solution offering ranked the lowest,indicating that payers generally go with a point solution approach,despite reporting mixed preferences for best of suite vs.best of breed.0%20%40%60%80%100%n=102n=102n=102n=102n=102n=102n=102n=102n=102n=102n=102n=102“Please rate the importance of eac
88、h of the following criteria when selecting an HCIT solution/vendor.Please answer on a scale of 1 to 7,where 1=Not at all important and 7=Extremely important.”PriceInternal system integrationExternal system integrationReporting analyticsEaseof useScalabilityCustomer serviceBreadth of data inputsAlgor
89、ithm sophisti-cationBreadth of solution offeringsSource:EY-Parthenon payer survey(n=102).?1=Not at all important7=Extremely important23456%6/778%68%63%63%63%57%54%51%51%50%48%43%Customi-zationBreadth offunctionality Section 5|How do payers select HCIT solutions?6 Substantially significant includes r
90、esponses for 6 and 7;respondents answered on a scale of 1 to 7,where 1=Not at all important and 7=Highly important.17The 2023 EY-Parthenon and KLAS Research Payer Tech Study|While plugging into a payers existing tech infrastructure is considered table stakes,interoperability with the providers ecosy
91、stem is highly differentiating this despite recent CMS guidelines requiring increased interoperability.Though these guidelines have elevated interoperability as a decision-making criterion,operationally,the industry is still far from achieving this(see Figure 5.2).Figure 5.2Table stakes and differen
92、tiating HCIT features(n=357)Not needed/appealing“When considering HCIT solutions/vendors,which features are considered tables stakes(minimum features required),which are differentiating(preferred or valued capabilities that are not minimum basicrequirements)and which are not needed?”1 Examples of pr
93、ovider systems include electronic health records(EHR)and practice management solutions.Source:EY-Parthenon payer survey(n=102).?DifferentiatingTable stakes0%20%40%60%80%100%Customer servicePredictive analyticsBusiness intelligencereportingInteroperability with payer systemsAI,ML andnatural language
94、processingautomation capabilitiesMargin and revenuediversificationCustomizationHigh-qualityuserinterfaceInteroperability with provider1Prescriptiveretrospective analytics Section 5|How do payers select HCIT solutions?Generally speaking,were looking for the absolute best for a specific function when
95、selecting a HCIT vendor.”“VP,regional plan18The 2023 EY-Parthenon and KLAS Research Payer Tech Study|The role of generative AI in HCITThe growing interest in generative AI(GenAI)has also left its mark on the payer HCIT industry.Payers are particularly interested in AI-enabled solutions aligned to th
96、eir strategic and HCIT areas of focus(see Figure 5.3).While interest exists,payers are also skeptical given the novelty of these technologies.Current usage of GenAI solutions is restricted to relatively low-risk applications,such as automating and improving call center operations.This gap between pa
97、yer interest in AI solutions for cost containment,member engagement,and payment integrity solutions and their availability in the market represents an opportunity for HCIT investment and innovation into automating repeatable tasks.Given the real implication,especially for human life,payers must cond
98、uct thorough due diligence prior to adoption and establish clear governance,oversight and override processes while using these solutions.Figure 5.3AI,ML and natural language processing(NLP)potential by solution0%20%40%60%80%100%n=75n=62n=50n=46n=39n=65n=43n=68n=54n=64n=33n=44“Across all of the categ
99、ories that you have insight into,which of the following areas are the best candidates for artificial intelligence(AI/machine learning/natural language processing)applications?”Source:EY-Parthenon payer survey(n=102).?23456%6/736%44%26%30%28%49%47%45%54%52%15%32%Interoper-abilityUtilization manage-me
100、ntCase+disease+condition manage-mentPopulation health manage-mentRisk and quality manage-mentMember engage-mentHealth equityWellness benefitsCAPS1=Low AI,ML and NLP application potentialPaymentintegrityand costcontainmentNetworkmanagementandoptimizationContractandperformancetracking7=High AI,ML and
101、NLP application potentialBenefits,billing and claims managementProvider engagement andmanagement Cost containmentMember focused Section 5|How do payers select HCIT solutions?19The 2023 EY-Parthenon and KLAS Research Payer Tech Study|We are working on automating the pre-authorization process using AI
102、 as much as possible,because the pre-authorization process can be long and costly.We will never get to the point where we deny a claim without somebody looking at it or deny an authorization request without eyes on it.But this will tee up that information so the eyes on it have what they need.We hav
103、e already automated about half of those.“We dont want to be a trailblazer when it comes to these sorts of innovations(e.g.,AI).We dont want to be,we think theres a lot of risk involved with that.We dont want to spend a lot of money on solutions that dont materialize.I dont know that we have any lead
104、ing vendors in AI right now.And its also difficult to cut through a lot of the smoke from the vendors in terms of whats real and whats not,whats truly AI and whats just a cleverly packaged algorithm.So,were still trying to figure that out for ourselves versus actually having some ideas.“Chief techno
105、logy officer Senior VP,regional BluesFigure 5.4Solution investment with AI and NLP capabilities?“When it comes to AI and NLP how likely is your organization to invest in solutions that utilize this technology?”Data collected from KLAS Research expert interviews(n=20).Source:KLAS Research interviews;
106、EY-Parthenon analysis.80%20%Private payersn=20HighlylikelyLikelyConclusionAs payers face turbulence in market conditions in the post-COVID-19 landscape,cost optimization has become paramount to addressing flagging profitability.HCIT is attracting growing investments and emerging as a key tool to for
107、tify payer value propositions,as well as remedy ballooning medical and administrative spend through innovative,member-centric savings strategies.Payers that fail to invest in a modernized tech stack risk falling behind competitors on margins,cost structure and value to members.GenAI is high risk and
108、 provides high rewards.Payers are interested in these solutions;however,they are cautious about adoption given the“black box”nature of these platforms.The macroeconomic forces across the industry,the changing nature of solutions coming to the market and the payer focus on HCIT solutions to combat sh
109、rinking margins make HCIT an attractive short-term investment opportunity.Section 5|How do payers select HCIT solutions?Survey demographics and methodologyDemographics The analyses and findings shared in this report are based on 102 clean complete responses to the survey from relevantrespondents.A c
110、lean complete response is one where the respondent has taken the time to go through the survey and providethoughtful responses.We screen out any response suspected of straightlining(i.e.,selecting the same response option for eachquestion)or those completed significantly under the anticipated time r
111、equired to complete the survey.The survey includes responses from multiple payer entities(national,Blue Cross Blue Shield(BCBS),non-BCBS regional,third-party administrator(TPA),etc.)servicing commercial(self-insured and fully insured),Medicare and Medicaid lines of business.Approximately 70%of the r
112、esponses came from traditional payers(national,BCBS,non-BCBS regional),while the rest consisted ofprovider sponsored,new age,and TPA and MSOs.Payers were segmented by the primary LoB served(40%or higher of total covered lives),as well as by the size of the total coveredlives,as follows:Jumbo:10.0m+c
113、overed lives Large:3.0m9.9m covered lives Medium:500,0002.9m covered lives Small:500,000 covered lives Respondents included were either the primary decision-maker or played a significant role in the decision-making process for HCITvendors at their organization.Title of respondents surveyed:C-suite(C
114、EO,CFO,etc.),president,executive or senior vice president,directorMethodology The survey consisted of 60 questions on a range of topics pertaining to HCIT investment themes and objectives,both historicallyand within the near term.Respondents were also asked to reflect on their experience using and e
115、valuating specific HCIT solutionsto explore HCIT investments at a micro level.The target audience was provided screener questions to identify those who had relevant experience and involvement in selectingHCIT solutions within their payer organization.The survey was web based and was fielded over the
116、 course of 1.5 weeks.Responses were then recorded and segmented to pullinsights from across the payer size,plan type and LoBs primarily served.Supporting research KLAS Research conducted outreach phone calls with 22 decision-makers from payers of all sizes and various types(national,regional,BCBS,ac
117、countable care organizations(ACOs),provider sponsored)across the US to further understand the rationalebehind payers HCIT investments and strategies.20The 2023 EY-Parthenon and KLAS Research Payer Tech Study|MethodologyEY-Parthenon contactsEY|Building a better working worldEY exists to build a bette
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124、S SCORE no.21605-231US CSG No. ED NoneThis material has been prepared for general informational purposes only and is not intended to be relied upon as accounting,tax,legal or other professional advice.Please refer to your advisors for specific Produced in collaboration withEY-Parthenon c
125、ontactsKLAS Research contacts Anirudh GoelPrincipal,EY-Parthenon,Ernst&Young LLP Jennifer HickenlooperSenior Insights D RuiRui Sun,PhDInsights Manager Deblina GhoshPrincipal,EY-Parthenon,Ernst&Young LLPAdditional acknowledgments and contributions The authors would like to thank the following team me
126、mbers for their invaluable contributions:subject-matter advisors Mallory Caldwell,Melinda Durr,Dan Shoenholz and Abby Johnson of Ernst&Young LLP.EY-Parthenon research contributors Chantel Brown,Caroline Skinner,Nickolas G.Monterroso,Fedjine M.Victor and Max J.Fuster.KLAS Research contributors Aurene
127、 Wilford,Joe Van De Graaff,Rebecca Hammond and Joel Sanchez.Niyati UpadhyayulaDirector,EY-Parthenon,Ernst&Young LLPKLAS is a research and insights firm on a global mission to improve healthcare.Working with thousands of healthcare professionals and clinicians,KLAS gathers data and insights on softwa
128、re and services to deliver timely reports and performance data that represent provider and payer voices and act as catalysts for improving vendor performance.The KLAS research team publishes reports covering the most pressing questions facing healthcare technology today,including emerging technology
129、 insights,that provide early insights on the future of healthcare technology solutions.KLAS also fosters measurement and collaboration between healthcare providers and payers and best practice adoption.Learn more at .We thank all survey respondents and interviewees for their contributions to this initiative.