Health Plans and Providers | ZS

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Florent Moise
Learn more about our Health Plans and Providers practice

Health Plans and Providers

According to National Health Expenditure data, $1.1 trillion or 34% of the total U.S. national health expenditure comes from what is typically described as “insurance”: private health plans, Medicare and Medicaid. And that spending will only increase as the country’s population continues to grow and age, leading health plans and providers to make smart decisions around how to serve consumers efficiently and effectively.


Working with our clients, we have identified several top-of-mind issues:


  • Revenue generation: Because commercial membership has reached saturation, health plans must look to new areas for growth via new services and increased member engagement. Additionally, Medicare Advantage is a large, untapped opportunity, but health plans must learn to communicate and engage with these members as consumers.
  • Evolving health plan landscape: Vertical integration between health plans, providers and pharmacy benefit managers is reshaping healthcare, just as new entrants into the space are promising new digital and virtual offerings. To stay competitive, health plans need to invent new business models and tackle the challenges of implementation.
  • Member centricity: Members are expecting more from their health plans: speed, responsiveness, service and personalization. Health plans need to meet the consumer standards established by other industries and provide coverage beyond illnesses, enabling improved health and access to care.
  • Data and analytics: The healthcare system generates a massive amount of data. Beyond claims data, health plans are looking to integrate EHR, connected devices, consumer information and social media to enhance member care and experience. In parallel, new technologies such as machine learning and artificial intelligence have yet to fulfill healthcare’s high expectations.
  • Cost containment: Value-based care is rapidly developing as a way to ensure fiscally responsible use of the healthcare system. In the quest for cost efficiency, health plans need to establish high-quality provider networks and design better value-based care programs. Moreover, health plans and PBMs need to manage the high price of pharmaceuticals and better plan for the rise of expensive specialty products.

ZS addresses these challenges by leveraging its more than 35 years of experience in the healthcare industry. We strive to integrate our offerings in consulting, operations and technology to develop solutions that work. With expertise, technology and practical implementation, we partner with health plans to pave innovative paths to success.

At ZS, we focus on the key business issues that our health plan clients face every day. Our solutions help clients in crucial areas such as:


  • Go-to-market strategy and customer engagement: Successful go-to-market strategies include a handful of components: identification of customer segments and needs, product development and value proposition design. ZS has extensive experience in both the business (broker and employer) and consumer worlds, employing primary and secondary research techniques to uncover insights and unmet needs. We then design and optimize marketing strategies to enhance new customer acquisition and member retention. We also help ensure continuous improvement by implementing and orchestrating engagement processes at the tactical level.
  • Provider network management: Creating an optimal provider network centers on two key issues: first, building the best network and refining it to ensure higher quality and better outcomes; then ensuring ongoing provider engagement using targeted programs and information exchange. ZS can help design high-performing networks by using providers’ activities, attitudes and behaviors, along with geographic optimization, and helps orchestrate the right provider experience to maximize impact across multiple channels.
  • Value-based care: The key to the success of value-based care is to identify opportunities for mutually beneficial relationships between stakeholders in healthcare ecosystems that will foster more innovation and accountability for outcomes. ZS is a leader in the design and administration of incentive plans that drive beneficial behaviors. We also often act as a trusted third party in the ongoing measurement and monitoring of the effectiveness of partnerships.
  • Data management: As data is getting richer and more diverse, the need to manage it efficiently has never been greater. This includes breaking down data silos, ensuring integration with different data sources and enabling the sharing of information across the organization as a single source of truth. ZS can design, implement and administer systems for data management, including data lakes, cloud-based environments, modern reporting and tailored solutions developed in partnership with major software providers. We can also help health plans build business-relevant artificial intelligence and machine learning tools, and provide the organization, governance and data strategy to fully utilize them. Our consulting focus helps IT become a better partner to business stakeholders.
  • Integrated analytics: Integrated analytics at ZS is focused on solving complex business problems using advanced analytics and technology; not simply building technologies that are looking for a business problem to solve. Our data scientists help uncover insights in multiple business areas such as health economics and outcomes research and predictive models to enable next best actions. These techniques are versatile and can be applied to many other aspects of health plan business issues, including population health, medication adherence support, the optimization of Medicare STARS ratings, engagement of members or providers, and much more.