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ERM and Claim Settlement Healthcare Trends for 2016

A recently completed survey of clients and healthcare leaders has revealed several 2016 trends. A combination of factors are influencing quality and costs in the industry. The top three survey results focus on the key underlying dynamics defining how risk and claim management leaders will manage future healthcare issues.

Executives in the risk and claim management fields are embracing healthcare industry changes to eliminate fraud, abuse and redundancy. The focus on optimizing health outcomes is paramount in the minds of leaders. The top survey results summarize the key components of individual healthcare decision making, and how they will make a difference in the enterprise risk management and claim settlement solutions fields.

1. Consolidation

The Affordable Care Act (ACA), so-called Obamacare, is driving many industry forces to understand and manage the quality and costs of healthcare through various traditional and new insurance mechanisms. As a result, many organizations are now facing underwriting losses due to significant costs for the most chronic care patients, and are repricing their insurance products to address the projected losses. United Healthcare announced recently that their exchange business may lose over $700 million when 2015 results are reported. In 2016 and the foreseeable future, look for the smaller regional networks, exchanges and insurers to be acquired or merged into larger, well-known brands. The deals will be more about cost savings, value and rebranding, not necessarily quality enhancements.

2. Pharmaceuticals

With escalating drug prices, there will even more pressure to use generic medications whenever possible. Additionally, biosimilar drugs which are allowed under Obamacare, will become more prevalent as the FDA approves more variations of expensive biologic drugs to reduce the cost of treatments. In general, most healthcare professionals agree that generic medications cut the cost of brand-name drugs by 60-80%. For biosimilar medications, the costs are cut by 20-30%. Greater access to these drugs and competition may improve cost cutting objectives even further in 2016 and beyond.

3. Technology

With an ever increasing number of technology applications to help patients and their families monitor healthcare issues, the healthcare field will literally “be in the hands” of consumers. Patients will have many more options for less costly self-managed care, offices, clinics and hospitals. Other options such as virtual clinics will become available due to a merger of the health and technology fields.

For instance, how will tools like the Apple Watch (including the Health App) and Fitbit be utilized to monitor key matters involving the healthiest to the most costly chronic individuals. Will these tools evolve to address self-insurance, deductible and insurance alternatives also?

Additionally, new data transparency and data driven practices will likely develop and grow to focus attention on the key factors that drive healthcare costs. These practices, called “hot spotting”, are now challenging the normal delivery system by identifying and benchmarking cases to question costly therapies and drugs before they are delivered. Will hot spotting eventually be available in applications so that individuals and their healthcare teams are all “on the same page” with what needs to be done?

Ultimately, the healthcare field will be more focused on delivering low cost, quality, holistic care utilizing all of the technology and professional service tools available.  For more about how our RiskPro applications and professional services are impacting healthcare costs, please contact us for additional information and a complimentary consultation.


Blackburn Robert

By Robert J. Blackburn, Managing Principal, Blackburn Group, Inc., contact him at This email address is being protected from spambots. You need JavaScript enabled to view it..

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