Detroit, Miami, New York have biggest ‘payvider’ opportunities

Detroit, Miami, New York have biggest ‘payvider' opportunities


Detroit, Miami, Phoenix and New York are among the markets with the most room for so-called “payvider” partnerships to grow, a new report finds.

The consultancy Guidehouse studied more than 100 U.S. markets’ populations, insurance enrollment and cost and quality metrics to compile its report, which is designed to help providers and insurers in each area decide whether to partner up or go it alone. Increasingly, payers and providers are boosting their returns by teaming up on risk-based collaborations, either in the form of partnerships or formal joint ventures with asset transfers.

The industry is at an inflection point in terms of how payers and providers are incentivized to keep patients healthy, said Dr. Nicole Fetter, a director with Guidehouse.

“Payers need providers to perform on quality, cost and access more than ever to earn full revenue potential,” she said, “and providers need payers and purchasers as they’re insuring the patients and members that the providers serve.”

Guidehouse found the metro areas around Detroit, Miami, Phoenix, Tampa and New York have the highest current Medicare Advantage and managed Medicaid penetration combined with expected enrollment growth. They also showed room for improvement on cost and utilization metrics such as Medicare per capita costs, Medicare Advantage star ratings and emergency department utilization.

Other metros in that category include Charlotte, N.C., Orlando, Cincinnati and Cleveland. Cleveland’s rating, for example, suggests there is substantial opportunity to boost value with respect to cost and quality, the report said. There’s also demographic shifts happening that will fuel growth in Medicare and Medicaid managed care membership.

Fetter acknowledged that the markets within each of the report’s categories are very different from one another, and said it’s because a variety of components go into the scores. For example, Miami scored low on value because its Medicare per capita costs are so high. In Detroit, by contrast, there’s poor primary care access and higher age-adjusted mortality.

Guidehouse’s report, the inaugural Center for Health Insights Payvider Market Index, only included metros with populations above 500,000 based on market size and future growth. It lists metros by population size, and Fetter noted that the larger the population, the bigger the opportunity for membership growth.

The report also grouped together Los Angeles, San Francisco, Riverside, Calif., Minneapolis and Albuquerque, N.M., and said those markets already have a lot of payers and providers coupled with strong cost and quality performance. Guidehouse said that means payers and providers could further differentiate existing value-based payment and delivery options.

In Albuquerque, there are several high-performing players and projected membership growth, the report said.

Another group that includes Seattle, Denver, San Jose, Calif., Salt Lake City and Des Moines, Iowa has relatively low value-based membership growth potential given projected demographic and payer changes, but the existing players score well on cost and quality. In the case of Des Moines, for example, potential Medicare Advantage and managed Medicaid growth is low, so players in that market may want to consider expanding their footprint elsewhere, Guidehouse said.

A fourth group that includes Chicago, Dallas, Houston and Washington, D.C. has low growth potential and didn’t perform as well on cost and quality. In the case of Dallas, Medicare Advantage is already high with significant competition. The real opportunity there is for the provider community to differentiate its population health and cost management capabilities, Guidehouse said.

The payvider trend is driven in part by the increased importance of Medicare and Medicaid in the health insurance businesses, especially Medicare Advantage. The biggest and most obvious example of a payvider is UnitedHealth Group’s Optum Care subsidiary, which has more than 53,000 doctors and 1,450 clinics nationwide.

Another example is the value-based care joint venture formed in 2016 between Phoenix-based Banner Health and Aetna that they ultimately extended with a longterm agreement in February 2021. Banner and Aetna said they’ve seen average cost savings of between 8% and 14%, better member experience and growth to approximately 350,000 members.

In the Detroit area, Henry Ford Health System formed a clinically integrated physician network in 2007 that brought together its medical group and independent providers to boost quality and efficiency. It’s now one of the country’s highest performing Next Generation ACOs and has a direct-to-employer partnership with General Motors.



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Marie Maynes
Marie Maynes is a Sports enthusiast and writes for the Sports section of ANH.