Ep 13 - Building a Modern Healthcare Network: Competitive, Cost-Effective, and Compliant Strategy

Third-Party Administrators (TPAs) and health plans have many things in common, but one that stands out is the challenge both are facing in today’s healthcare industry. With digital transformation, ongoing demographic shifts, and a variety of other long and short-term trends, TPAs and health plans are facing significant headwinds when it comes to creating a modern healthcare network.

Despite these challenges, there are many ways for TPAs and health plans to create competitive, cost-effective, and compliant networks. “Meeting member needs, and by extension reducing member abrasion, is one of the industry’s largest challenges,” said Maisie Weir, Director of Business Solutions. Weir noted that Zelis has found that by empowering health plans and TPAs to build, access, and manage networks it is possible to reduce pressure around resource constraints, and ultimately create high-performing network solutions.

Erick Russel, Director of Network Operations at Zelis added that among the specific issues facing TPAs, finding ways to deliver value and creating access to strong networks is key to thriving in the modern healthcare network ecosystem. Russel added that “TPAs also need to be aware of how provider pricing variability has had a major impact on driving up traditional healthcare costs.”

Payers have been searching for new strategies to help stabilize claim costs, Russell added. Indeed, his team at Zelis has seen an increase in the need for network replacement solutions, which he noted often included some form of reference-based pricing.

But apart from the more industry-specific trends driving change, Kim Sharbatz, Senior Director of Strategic Network Partnerships, pointed to an overarching trend that is having an outsized impact on the industry. “We’ve said it time and time again, but in today’s world everything is virtual,” Sharbatz told FHT. “That means our workforces must become virtual as well.”

This evolution has created challenges for health plans and TPAs because memberships have become widely dispersed which can make it difficult to build and manage network solutions to fulfill their access for their members. Sharbatz argued that creating a modern healthcare network requires a health plan or TPA to dedicate a large number of its resources to really understand networks and the market, or alternatively “they can work with a partner who already does all that and more.”