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Organizations responsible for paying for healthcare – health insurance carriers, health plans, employers, and governmental organizations – rely on analytics and reporting software to improve performance and better understand their members and clinician networks. This report reviews the current state of the market, categorizes the different kinds of vendors and solutions, and evaluates 18 vendors’ capabilities for meeting the needs of their payer customers. It complements the Provider Analytics MTR that was released in early 2019 and focuses on the solutions that are enabling greater payer efficiency, cost and quality measurement, contract management, and network optimization.
Vendors Profiled: Arcadia, CareEvolution, Cerner Corporation, Certilytics, Change Healthcare, Clarify Health Solutions, Cotiviti, Health Catalyst, HealthEC, IBM Watson Health, MedeAnalytics, Medecision, Milliman, Optum, Philips, SCIO-EXL, SPH Analytics, ZeOmega.
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Preview the table of contents, executive summary, first page of market analysis, and overview of vendor types:
Historically, payer analytics vendors used claims data almost exclusively. This data source, although time-lagged, supports a robust set of applications that meet many performance improvement needs for different kinds of payers. More recently, payers have begun adopting analytics technology to support the transition from fee-for-service (FFS) to value-based care (VBC). The variety of pay-for-performance (P4P), pay-for reporting (P4R), and risk- and revenue-sharing programs with providers has caused payer organizations to invest in applications that help balance cost and quality through a better understanding of their members’ healthcare needs and risks. These applications need combined provider and payer data to deliver insights to users, and allow payers and providers to share a common understanding of cost, quality, and utilization performance described in value-based care contracts.
For now, cost, quality, and utilization reporting remain the common thread among organizations using analytics tools, looking to achieve immediate goals like improving HEDIS measures and HCC scores, finding fraud, waste and abuse, and controlling total cost of care and identifying cost drivers. Payers are also turning to advanced analytics to predict a range of outcomes, costs, and events.
However, capitalizing on the value these tools provide remains a challenge. Payers find that current analytics tools are excellent at identifying areas for improvement but need engaged clinicians and members to take appropriate action. The offerings also need to do more to offer non-analysts the actionable insights they need to make measurable changes on their own.
This comprehensive report provides an overview of the payer analytics and reporting market and evaluates offerings from 18 leading vendors, classified under three categories based on data focus: claims analytics, clinical analytics, and technology-enabled services vendors. Each profile includes an assessment of the vendor’s strengths and challenges, plus detailed descriptions and evaluations of both the product capabilities and market execution across 21 categories.
Lead author Brian Murphy hosted a webinar presenting and discussing the report’s key findings — watch here.