Peering into the crystal ball: Health care purchaser strategies for 2025

At Catalyst for Payment Reform, we are fortunate to work with some of the nation’s most innovative employers and other health care purchasers. Year in and year out, these visionaries attempt to tackle the big, foundational issues plaguing the nation’s health care system through benefit and network design strategies, payment and delivery reforms, and price transparency.

By setting the example for others and sharing the lessons they learn and their best practices, these innovators inspire a groundswell of others who follow their lead. The strategies they employ serve as a crystal ball through which we can identify potential future trends. As we enter 2022, here are a few of the newest, noteworthy purchaser strategies being implemented by our nation’s most forward-thinking buyers of health care.

Eliminating a high-priced provider from a network

32BJ Health Fund, a multi-employer union trust fund that provides benefits to 190,000 people, many of whom are in the New York City region, announced in June that it would remove a high-priced provider, New York Presbyterian, from its network effective January 1, 2022. This news may indicate that for some employer-purchasers, high health care prices have created a tipping point and more purchasers will embrace narrow networks, high-performance networks, or carving a particular high-priced provider out of the network.

Partnering with a market-shaping third-party administrator

Equity Healthcare, which buys health care for Blackstone’s Portfolio Companies, will offer benefits through Centivo, a new third-party administrator (TPA) focused on value-based care, beginning January 1, 2022. In recent years, an increasing number of TPAs offering varying business models and value propositions have entered into direct competition with health plans for self-insured purchaser business.

Offering virtual care through a direct contract partner

General Motors made a splash a few years ago when they launched a direct contract with Henry Ford Health System (HFHS). The auto manufacturer has since expanded this arrangement, opening a virtual care center operated by HFHS staff at its Global Technical Center in Warren, Mich. With the COVID-19 pandemic, the use of virtual care skyrocketed and remains above pre-pandemic levels while many health plans are even beginning to offer virtual plans.

Betting bigger on episode-based payments

For years, the state of Washington’s largest purchaser, Washington State Health Care Authority (HCA), has implemented transformative strategies such as an accountable care program and bundled payment for joint replacements and spine fusion on behalf of its plan members, which include public employees, school employees, retirees and their eligible dependents.

Effective January 2022, HCA will participate in Regence Blue Shield’s Episodes of Care program, offering coordinated care and episode-based payment for orthopedic procedures, cardiac procedures, gastrointestinal conditions, and maternity care. Regence has partnered with Signify Health, a company that administers episode-based payments to health care providers, to operate the program. Episode-based payment is a promising alternative to paying fee-for-service, but has yet to achieve any scale in the U.S.

Advancing maternity care by piloting doula coverage

Walmart, the nation’s largest private employer, aims to improve maternity care and announced a pilot in Georgia to enhance access to doulas. Doulas provide education and support for expectant mothers during pregnancy and while in labor. This is welcome news, as CPR has observed limited progress with improving the quality of maternity care, including the continued high rate of cesarean sections. There has also been limited progress with the implementation of strong incentives for providers to follow maternity care guidelines.

Will more employers and other purchasers carve high-priced providers out of their networks and/or embrace high-performance networks? Will providers increasingly accept bundled payment? Will the nation turn the corner from its abysmal record on maternity care outcomes? Only the crystal ball knows the answers. But with these purchasers leading the way, 2025 and beyond is looking brighter.

Ryan Olmstead is director of member services for Catalyst for Payment Reform.