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Top 5 healthcare payors

*updated March 2022

As of 2020, the average deductible for a median-income household was 4.7% of total income. This is an increase from 3.3% in 2010. Higher deductibles could result in providers denying care, patients reluctance to seek care, and increased spending on charity care, all which would negatively affect a health care payer’s bottom line.

Reading: What does payor mean in health insurance

The good news is that payers can reduce expense waste and manage costs effectively in an uncertain market using all payers’ claims databases and blockchain.

We compiled this list to determine which payers receive the highest total direct premiums.

top 5 health care payers by total direct premium earned

classification

payer

premium earned

lives covered

1

kaiser Permanente health plans

$55,596,803,838

9,257,115

2

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anthem blue cross & blue shield

$38,208,158,726

5,837,538

3

united health

$39,190,537,411

7,210,507

4

group of healthcare services companies

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$31,336,017,522

5,012,197

5

floral blue

$17,405,136,863

2,375,334

fig 1.data from the definitive database of healthcare payers. data consulted in March 2022.

what is a health care payer?

The term “payer” refers to preferred provider organizations (PPOS), health maintenance organizations (HMOS), health care service contractors, state insurance agencies, claims processors, and more. The main difference between a health plan and a payer is that a health plan pays the cost of health care and a payer is an entity responsible for processing a patient’s eligibility, services, claims, enrollment, or payment.

payer vs payer

There is some conflict regarding the use of “payer” versus “payer”. Although people often use both spellings interchangeably, the American Medical Association (AMA) prefers “payer.”

We also looked at which payers covered the most lives. see below.

top 5 health care payers per covered lives

classification

payer

lives covered

premium earned

1

kaiser Permanente health plans

9,257,115

$55,596,803,838

2

united health

7,210,507

$39,190,537,411

3

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anthem blue cross & blue shield

5,837,538

$38,208,158,726

4

group of healthcare services companies

5,012,197

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$31,336,017,522

5

centene corporation

2,644,427

$16,753,644,749

fig 2.data from the definitive database of healthcare payers. data consulted in March 2022.

what was the main payer for earned premiums and covered lives?

Kaiser Permanente health plans were the top payers for premiums earned ($55,596,803,838) and lives covered (9,257,115 lives). along with Kaiser Permanente, Anthem Blue Cross & blue shield, united healthcare and health care service corporation group were among the top five in both premiums earned and lives covered. In total, the top five payers earned $181,736,654,360 in premiums and covered 29,961,784 lives.

how can health care payers reduce overspending?

all payer claims databases

All Payer Claims Databases (APCDs) are electronic systems that collect health care claims data from payers. As of 2020, 21 states had an APCD, and 11 states were interested in implementing one. To develop an APCD system, state governments must assess the local health care market. This includes evaluating the health insurance market and public payers, developing data submission guidelines, and managing patient health data.

Although it seems like a huge amount of work and can be expensive to maintain, the payoff is significant in managing population health and reducing healthcare spending. Because APCDs are state systems, they simplify the exchange of data between payers, providers, and regulators. this allows easy analysis of medical claims and identification of areas to avoid financial waste.

Wasteful spending costs employers up to $2 billion per year or about one-fifth of total spending, according to a 2017 report from the American Health Policy Institute (AHPI).

apcds can also educate payers and other stakeholders about areas that overuse health care services or where preventive care could have had a positive impact on overall spending. Once payers have this data, they can work with providers to deliver more comprehensive care, thereby improving care outcomes and lowering costs. For example, an NIH study that reviewed APCD data in Virginia found that unnecessary low-cost health care services, such as lab tests and EKGs, cost more than $586 million a year.

blockchain

a 2020 cms report shows that out-of-pocket spending accounted for 9% of total national health spending. This means that patients will have higher expectations for care outcomes, provider communication, and data security. Like today’s EHR systems, blockchain facilitates communication between providers and payers, making data easily accessible to those who have permission to see it.

Blockchain is an expandable list of electronic records that are connected and protected using encryption technology. Blockchain adoption in healthcare has been slow to start, but it has great potential as electronic health records (EHR) and electronic medical records (EMR) become virtually ubiquitous.

Since ehr systems and healthcare facilities can be vulnerable to cybersecurity breaches, implementing blockchain could save the healthcare industry up to $100 billion per year by eliminating fraud.

Like APCDs, blockchain compiles massive amounts of patient data, allowing for easier analysis. this could allow employers offering health plans to see the categories of care that cost the most money and implement wellness initiatives to combat them. Blockchain could offer a window into why patients seek care, whether for smoking cessation, weight loss or other areas.

more information

By combining billions of private prescription and medical claims with CMS and proprietary data, Ultimate Healthcare enables its users to better analyze healthcare market trends, develop comprehensive segmentation strategies, identify industry leaders and refine sales and marketing strategies.

Explore more about how healthcare business intelligence can help you grow your business by starting a free trial today.

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