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Next Generation Payer Care Management: Why Now, and What Next?

Payer care management isn’t new. For decades, care managers have been providing information, support, and guidance to members facing chronic and acute healthcare challenges and complex transitions of care. Care management not only improves healthcare outcomes, but can also help health plans avoid unnecessary healthcare costs.

So why the recent attention on payer care management?

The answer is based on two ubiquitous drivers of change in the post-pandemic era. First is the increasing prevalence of physical, behavioral, and comorbid chronic health challenges caused or exacerbated by COVID-19. [1],[2] These challenges include the ongoing physical and mental symptoms associated with the virus in its acute and long form, as well as the secondary impacts including loneliness, depression, and anxiety. Second is digital transformation. This long-existing trend was significantly accelerated by the pandemic and our need for social distancing and remote solutions. In tandem, these two factors have increased the magnitude of opportunity for innovative and effective care management. They have also magnified the risk for missed-opportunity costs for payers who are not making the most of available solutions and existing digital investments, particularly in the world of care management.

McKinsey & Company has put forth an expended definition of care management which includes “…any payer-driven efforts to engage with targeted members and their care ecosystems to encourage and enable high-value decisions around their care and improve self-management…including traditional telephonic or in-person interaction as well as digital and asynchronous “coaching” and tech-enabled “nudges” [3]. Further, McKinsey estimated a 2:1 ROI for payers who can implement a care management model with the right processes, data, technology, and timing.

Key model components include:

  • Identifying and targeting high potential sources of value by member archetype
  • Engaging members using consumerist tactics
  • Calibrating service intensity to key moments in a care journey
  • Running care management as a data-based operation

While the ROI potential is clear, and the model imminently useful, this may not be something many payers are able to run with quickly. These key components require operational, procedural, technological, and possibly even marketing resources, oversight, and collaboration. This sets the stage for competing priorities that can leave many leaders unsure of where to even start.

This is where the company one keeps may really come into play. Today, most payers are using a care management platform or technology. But are they using it well? Is the technology optimized – and/or   are processes optimized for the technology? Could relatively small staff skills enhancements create big opportunities?

Payers with the right digital partners won’t have to answer these questions on their own. Instead, care management leaders have expertise to lean on, not just for technical support, but for clinical and transformational consultation as well. An external partner like HealthEdge with a solution such as GuidingCare will have insight gained working with a variety of health plans at varied stages of care management transformation, will be aware of common missteps and know the payer industry. With the advantage of distance and prior experience, trusted consultants can share invaluable advice on where to start based on current state and immediate priorities.

Don’t want to go on the journey of seeking next generation care management alone? Learn more here about how HealthEdge can help.


[1] The Healthcare System Is Facing Higher Acuity And More Sick Patients (


[3] The untapped potential of payer care management | McKinsey