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US Health
Insurance Trends
EMERGING TRENDS
2020
CB Insights is a tech market intelligence
platform that analyzes millions of data
points on venture capital, startups, patents,
partnerships and news mentions to help
you see tomorrow’s opportunities, today.
WHAT IS CB INSIGHTS?
CLICK HERE TO LEARN MORE
3US Health Insurance Trends 2020
Table of Contents
CONTENTS
NExTT framework				4
NECESSARY	
Health savings accounts				 7
Medicare Advantage (MA) supplemental benefits	 9
Self-insured employer experimentation		 11	
Payviders and verticalization				 14
EXPERIMENTAL	
Blockchain				16
Health sharing ministries				 18
TRANSITORY	
Big Tech inroads				 19
Pricing transparency				21
THREATENING 	
Social determinants of health (SDOH)			 23
Digital front door				25			
Risk carve-outs				27
4US Health Insurance Trends 2020
US Health Insurance Trends 2020
NExTT FRAMEWORK
5US Health Insurance Trends 2020
We evaluate each of these trends using
the CB Insights NExTT framework.
The NExTT framework educates
businesses about emerging trends and
guides their decisions in accordance with
their comfort with risk.
NExTT uses data-driven signals to
evaluate technology, product, and
business model trends from conception
to maturity to broad adoption.
The NExTT framework’s 2 dimensions:
INDUSTRY ADOPTION (y-axis): Signals
include momentum of startups in
the space, media attention, customer
adoption (partnerships, customer,
licensing deals).
MARKET STRENGTH (x-axis): Signals
include market sizing forecasts, quality
and number of investors and capital,
investments in R&D, earnings transcript
commentary, competitive intensity,
incumbent deal making (M&A,
strategic investments).
NExTT Trends
6US Health Insurance Trends 2020
For many, health insurance is an enigma.
Healthcare pricing is notoriously opaque, health plan acronyms seem to
span the whole alphabet (HDHP, EPO, HMO), and navigating the industry
requires a whole new vocabulary of specific, often unintuitive terms.
Add in some complex economic concepts (like “moral hazard,” “quality-
adjusted life years,” and “risk pooling”) and we get a market that impacts
all but is understood by few.
The industry sits at the crossroads of actuarial math, technology, policy,
and consumerism — each of which have the potential to drastically
impact the way healthcare is paid for.
As US healthcare costs continue to skyrocket, and with life expectancy in
the US decreasing for consecutive years, the conditions are ripe for big
changes to how care is paid for and delivered.
In addition to this, there are a number of macro trends that will
necessitate changes to the US healthcare system.
Between 2010 and 2030, the US population as a whole is expected to
grow by around 40M. With over 10,000 baby boomers turning 65 each
day, the United States currently lacks the infrastructure to care for this
population in traditional settings like nursing homes and assisted living
facilities. As a result, care will likely shift to new settings like the home.
At the same time, tech giants like Apple, Google, and Amazon are dipping
their toes into the insurance space, and companies are increasingly
exploring health insurance applications of emerging technologies like
blockchain and AI chatbots.
As the negotiators and allocators of care, insurers are at the forefront of many
changes in the healthcare industry. In this report, we dive into 11 key trends
that will impact the US health insurance landscape over the next few years.
What’s next for US health insurers? We looked across
the industry to identify 11 of the biggest payer trends,
from blockchain to digital front doors.
7US Health Insurance Trends 2020
HEALTH SAVINGS ACCOUNTS
The health savings account industry is a big beneficiary of rising
deductibles in employer-sponsored insurance.
Health Savings Accounts (HSAs) are one of the more underappreciated
tax-advantaged opportunities offered in the US today.
These accounts allow individuals in qualified health plans, or plans with
deductibles higher than a certain threshold, to contribute pre-tax money
to an account for health expenses. With deductibles rising across
employer plans, more plans are becoming eligible for HSAs: 23% of
workers in 2019 had an HSA, compared to just 6% in 2009, according to
the Kaiser Family Foundation employer health benefits survey.
HSA owners can spend their account’s money on health-related
expenses or keep the money invested in their accounts, earning interest.
(Unlike a flexible health spending account (FSA), money in an HSA can
roll over year-to-year.) HSA deposits are estimated to reach $75B in
2020, according to Denevir.
Source: Denevir
Necessary
8US Health Insurance Trends 2020
HSAs are often described as having a “triple tax advantage,” this is
because:
•	 Individuals can contribute pre-tax earnings without paying income
taxes on a federal or state level
•	 That money can be invested and grow on a tax-free basis
•	 If applied to qualifying expenses, that money can be withdrawn
tax-free ahead of retirement
Three startups looking to modernize HSAs raised money in 2019: Bend
Financial, Lively, and Starship. Each is attempting to bring the latest
in fintech — such as robo advisers, fee-free transfers, and overflow
investing — to take a piece of the large and growing HSA space.
As millennials (the most active users of popular fintech platforms
like Robinhood and Cash App) continue to accrue more wealth, and
awareness grows of the potential benefits of HSAs, look for the HSA
space to take off in the coming years.
9US Health Insurance Trends 2020
MEDICARE ADVANTAGE SUPPLEMENTAL BENEFITS
Medicare Advantage insurers are offering new benefits in the hopes
of attracting new members, improving outcomes, and cutting costs.
There was a time when offering benefits like vision, hearing, and dental
was an effective tactic for luring new members to Medicare Advantage
(MA) plans. But with insurance giants seeing MA as a major growth
area, and with 4 unicorn startups (Oscar, Clover, Bright, and Devoted)
looking to take a piece of the market, basic benefits like these are
becoming standard for insurers trying to win over new members.
Insurers are beginning to offer new types of benefits to differentiate
themselves, usually with one of two goals: attract new members or
lower health costs.
One benefit offering that aims to attract new members is UnitedHealth’s
partnership with Warby Parker to offer discounted glasses. Other
examples include insurers that offer discounted wearable devices like
Apple Watches and FitBits, as well as free gym memberships.
Source: Kaiser Family Foundation
10US Health Insurance Trends 2020
Moreover, many insurers are partnering with ride-hailing companies like
Uber and Lyft to offer non-emergency medical transportation (NEMT)
benefits to members. As government rules around supplemental
benefits continue to encourage more experimentation, look for NEMT
offerings to continue to grow.
Another common type of MA benefit looks to lower overall health
expenditures.
Because only around 10% of MA members voluntarily change plans
each year, insurers have an incentive to make longer term investments
in member health. As a result, payers are investing in benefits related
to chronic disease management and mental and behavioral health
(by offering access to platforms like Talkspace), which they hope can
provide a return on investment over the long term.
Some of the common partners for these efforts include Livongo, Omada,
and Uber.
11US Health Insurance Trends 2020
SELF-INSURED EMPLOYER EXPERIMENTATION
With the opportunity to save money and improve employee efficiency
and satisfaction, self-insured employers will continue to adopt new
care models and technologies.
A “self-insured” employer takes on insurance risk for its employee
population. To accomplish this, it usually signs an “administrative
services only” (ASO) contract with an insurance company and gets an
insurance policy to cover the company in case its healthcare costs are
unusually high in a given year. Under these ASO contracts, insurers
typically build out a network on behalf of the self-insured employer and
negotiate rates. Self-insured plans cover an estimated 94M employees
in the US.
Despite associated risks, we continue to see experimentation in the
self-insured population, as employers seek to provide better care to their
employees at lower costs.
Self-insured employers can keep the savings they generate by
reducing costs, can improve company efficiency by promoting healthier
employees, and can use quality health benefits as a marketing tool
to attract talent. Self-insured employers with broader healthcare
aspirations can also use their employee population to test new
approaches to care before rolling them out to the public.
One company working on this is Walmart, which has established some
unique programs to manage the health of its 1.5M US employees.
12US Health Insurance Trends 2020
For example, Walmart offers to pay the full cost to fly out its employees
to receive complex care at national “centers of excellence” like
Cleveland Clinic for cardiac surgery and Johns Hopkins for joint
replacements. The retail giant also partnered with Embold Health to
identify the best doctors for its employees in certain regions, and is
testing out personal “care concierges” for some of its employees.
Private companies are also raising funds to build out plans for self-
insured employers. Health benefits platform Collective Health has raised
$434M from investors including Google Ventures, NEA, and SoftBank.
13US Health Insurance Trends 2020
Employer-focused primary care group Paladina Health has raised
$165M, while disease management platform Omada has raised $201M.
Companies primarily serving the employer market have also seen IPOs
in the past year, including One Medical, Livongo Health, and Progyny,
and have shown positive ROIs for their customers. Accolade, a care
navigation upstart that raised $215M from investors including Humana,
Independence Blue Cross, McKesson Ventures, and Andreessen
Horowitz, filed its S-1 in late February and disclosed close to $100M in
revenue in the most recent fiscal year.
A key self-insured employer experiment to watch is Haven, the
collaboration between Amazon, JPMorgan, and Berkshire Hathaway to
manage care and simplify coverage for their 1M+ combined employees.
However, little has been made public about the partnership aside from
some high-profile hires and a few plan offerings that include wellness
incentives and have no deductibles. Separately, Amazon is offering
home visits and telemedicine to employees in the Seattle area through
Amazon Care.
Going forward, look for employers to continue to experiment with new
models of care for their employee populations
14US Health Insurance Trends 2020
PAYVIDERS AND VERTICALIZATION
Many companies are betting that combining the roles of payers and
providers can reduce costs and improve care outcomes.
Over the last few years, the traditionally distinct lines between healthcare
payers’ (insurers) and providers’ functions have blurred. Instead, we’re
beginning to see providers take on more risk, while payers are increasingly
buying up providers and steering members to their own facilities.
In a value-based healthcare system, this verticalization is rational, as
it aligns parties to deliver quality care at lower costs. (In contrast, the
traditional fee-for-service system incentivizes volume over quality.)
		
Source: Chilmark Research
Startup insurer Devoted Health has raised almost $369M, most recently
15US Health Insurance Trends 2020
at a $1.8B valuation, to build out a Medicare Advantage offering with
this “payvider” model in place. While Devoted’s verticalization focuses
primarily on primary care, Humana has taken the approach to post-
acute care — such as rehabilitation or palliative services. Over the last
few years, the insurance giant acquired a portion of Kindred at Home,
the country’s largest home health and hospice provider, and bought
hospice care provider Curo Health Services with the aim of improving
outcomes for its patient population.
Humana also recently partnered with private equity firm WCAS, a partner
in the Kindred deal, to invest approximately $600M into a new primary
care joint venture that could more than double its primary care footprint.
Blue Cross Blue Shield plans across the US have also opened their own
clinics. For instance, BCBS of Texas, Florida Blue, and BCBS of Tennessee
have opened medical centers in partnership with Sanitas Medical to
deliver services like primary care, urgent care, and diagnostic imaging.
At the same time, providers are seeing an opportunity to benefit from
the savings that they can generate by taking on insurance risk. Some
of the country’s most prominent health systems — including the Mayo
Clinic and the Cleveland Clinic — are now bearing risk for portions of the
patient populations in their surrounding areas.
16US Health Insurance Trends 2020
Experimental
BLOCKCHAIN
Incumbents have begun to research applications of blockchain
technology in healthcare.
Two large partnerships have formed to use blockchain technology to
help solve complex healthcare problems. The first, led by IBM, includes
Anthem, CVS, HCSC, BHI, and PNC. The second, called Synaptic Health
Alliance, includes United, Optum, Humana, CVS, Ascension, MultiPlan,
and Quest Diagnostics.
One early goal for each collaboration is to establish live directories
of in-network providers on the blockchain, with the aim of allowing
insurers to update their networks in real time for members to access.
This has historically been a pain point for patients, who have had
difficulty keeping track of when providers join or leave their networks.
17US Health Insurance Trends 2020
Another potential application for blockchain is tracking medications.
The Drug Supply Chain Security Act states that drugs will need to
become traceable throughout the pharmaceutical supply chain, from
the manufacturer all the way to the end-user.
Similar to food and grocery companies using blockchain technology to
drive food safety across the supply chain, blockchain technology has
the potential to be a significant aspect of future drug tracking solutions.
18US Health Insurance Trends 2020
HEALTH SHARING MINISTRIES
Health Sharing Ministries have ballooned in popularity, but may be
susceptible to policy changes and economic downturns.
Health sharing ministries are growing fast, going from covering 160,000
people in 2014 to more than 1M today, according to the Alliance for
Health Care Sharing Ministries.
Health sharing ministries are cost-sharing organizations for individuals
that "have a shared common ethical or religious belief." These plans,
which tend to be much cheaper than traditional health insurance,
require relying on other members to send payments to help cover
healthcare bills after care is provided. The three biggest ministries are
Samaritan, Medi-Share, and Christian Healthcare Ministries.
These plans are not regulated in the same way as traditional health
insurance. For example, they don't have to keep reserves to pay future
claims, don't have to require out of-pocket maximums, often don’t
accept new members with pre-existing conditions, and can deny
coverage if they deem a member’s expenses or behavior immoral.
We're seeing many different insurance products that are purposefully
being structured to attract young, healthy people that don't have a ton
of money to spend, but see their health insurance premiums slowly
rising. Short-term plans, self-insured plans, health sharing ministries,
and more are all approaches that young people are using to find
cheaper coverage.
However, these plans work until they don't — like when people have
serious healthcare issues, or when the economy takes a tumble.
19US Health Insurance Trends 2020
Transitory
BIG TECH INROADS
Big tech companies are starting to dabble in areas related to health
insurance. Look for that trend to continue in 2020 as tech giants
look to recoup the savings their technologies generate for the
health system.
Big tech companies are picking up steam in the healthcare space,
from Google in devices and data, to Amazon in the pharmaceutical and
hospital supply chains, to Apple in personal data and wearables.
And now, tech giants are venturing into health insurance through
partnerships and investments.
Of the big tech players, Google has made the most moves in the
insurance space thus far. Its $375M investment in Oscar Health in
August 2018 reportedly brought its stake in Oscar to around 10%,
including investments from other Google entities in previous rounds. It
also currently holds positions in Clover Health, an insurance startup in
the Medicare Advantage space, and Collective Health, which acts as a
carrier for self-insured employers.
Amazon has made moves in the health insurance space as well. The
retail giant now accepts HSAs and FSAs for health-related purchases
on its site. It is also working with insurer Cigna to develop an app for its
now HIPAA-compliant Alexa devices, and has partnered with JPMorgan
and Berkshire Hathaway on an initiative called Haven to manage
employee health (more on Haven in the self-insured employer section).
Finally, Amazon and Blue Cross Blue Shield of Massachusetts have
announced that PillPack by Amazon Pharmacy has been integrated into
the insurer’s member app.
20US Health Insurance Trends 2020
Apple’s entrance into the health insurance space has revolved around
the Apple Watch. The company has partnered with a number of insurers,
including United and Devoted Health, to offer subsidized watches to
members with the aim of incentivizing wellness and monitoring health.
Apple has also partnered with Aetna: the two companies worked
together on an app called Attain, which provides “nudges” towards
healthy behaviors and encourages members to be active.
Finally, Apple’s health kit and personal electronic medical record (EMR)
systems position it well to manage data on behalf of insurer partners.
But big tech has only scratched the surface of health insurance and
may soon move to take on insurance risk. To do this, we may see
Google, Apple, or Amazon start, partner with, or acquire a health plan in
the near future.
21US Health Insurance Trends 2020
PRICING TRANSPARENCY
Macro consumer and political trends are pushing the healthcare
industry to be more transparent about pricing.
One central goal of pricing disclosure policies is to make healthcare a
more competitive marketplace where consumers could shop around
based on price. In 2019, the Trump administration announced a policy
that would require hospitals to disclose their negotiated pricing for
common services on an publicly available online tool, and also hinted at
the potential to require the same of insurers.
But beyond this legislation, some players in the healthcare industry are
independently moving towards more transparency.
As deductibles continue to rise and patients pay for increasing amounts
of care out-of-pocket, many patients are agitated about the variability
in pricing for commoditized medical services. In response, some
big players, like CVS and Walmart, have started to list prices on their
websites for common healthcare services available at their clinics.
Several startups are also aiming to simplify healthcare pricing for
their consumers.
GoodRx, last valued at $2.8B, is looking to increase price transparency
for cash-paying customers who buy prescription drugs. The company
aggregates pricing for drugs at local pharmacies and directs its
customers towards the lowest cost options. This works especially well
because prescription drugs are commoditized — customers receive the
same product regardless of which pharmacy they get their drugs from.
22US Health Insurance Trends 2020
Slingshot Health is creating a marketplace for less commoditized services
like medical appointments and procedures. The startup uses a reverse
auction process, in which a patient can input the services they are looking
for and their availability, and providers compete by bidding the lowest
price they are willing to accept for the service. Other startups working to
increase transparency in the system are Healthcare Bluebook, Carrum
Health, and MDSave.
Source: Bind
Meanwhile, startup Bind is looking to rebuild the entire health insurance
offering with transparency at its core. The company eliminates
deductibles and co-insurance in favor of transparent prices for members.
Insurance giant UnitedHealth, an investor in Bind, seems to be seeing
traction in the company’s model and referenced Bind three times on
a recent earnings call, according to CB Insights’ earnings transcript
analysis tool.
23US Health Insurance Trends 2020
Threatening
SOCIAL DETERMINANTS OF HEALTH (SDOH)
Insurers are beginning to realize that social determinants may have
more of an impact on health outcomes than care itself.
Social determinants of health (SDOH) was one of the buzziest terms
in healthcare in 2019. The term came up on earnings calls more than
twice as many times in 2019 than in all prior years combined, while news
mentions of SDOH have skyrocketed since 2015.
SDOH refers to the conditions “in which people are born, grow, live, work
and age that shape health,” according to the Kaiser Family Foundation.
Targeted investments in these areas — which include housing,
food security, education, and community — are one way healthcare
stakeholders are looking to lower costs and improve healthcare
outcomes. Many communities already have programs in place that work
to tackle these issues.
24US Health Insurance Trends 2020
Companies like Unite Us and WellFrame are working on solutions that
direct individuals towards available resources, including food kitchens
and free legal assistance. Investors and partners for the two startups
include payers such as Blue Cross Blue Shield Venture Partners, CVS
Health, and Kaiser Permanente.
Going forward, we may start to see the conversation shift to structural
determinants of health as well. Structural determinants of health refers
to policies and infrastructure in place that ultimately feed into these
social determinants, like Medicaid expansion and laws surrounding HIV
status disclosure.
25US Health Insurance Trends 2020
DIGITAL FRONT DOOR
Incumbents and newcomers alike are fighting to be patients’ first
interaction with the increasingly digital healthcare system.
One way payers are aiming to lower costs and improve outcomes for
their members is to be the first point of contact for people interacting
with the healthcare system.
From there, payers can navigate members to the optimal provider and
care settings for a specific condition. For example, a patient with cold
symptoms could be sent to be treated by a nurse in an urgent care
center instead of a doctor in an emergency room. This approach can
help members avoid costly emergency room visits for minor ailments
like sore throats and small cuts.
Healthcare players are working on these types of solutions through
each of the build, buy, and partner pathways.
Oscar, for example, has built an app in-house that, together with its
website, serves as the company’s digital front door. The company
claims 41% of its members are monthly active users on either its app
or its website, and reports that 63% of members’ healthcare system
interactions are virtual.
26US Health Insurance Trends 2020
						
Source: Oscar Health
Anthem, meanwhile, is partnering to establish a digital front door for
its members. The insurance giant is working with a startup called K
Health to develop an app for its members. The app, called CareSpree,
incorporates the startup’s AI-powered chatbot to show patients
common diagnoses for prior users who have experienced similar
symptoms. The app then facilitates telehealth visits with doctors for
interested users.
Amazon appears to be taking the “buy” route to the digital front door.
The tech giant recently acquired Health Navigator, which provides online
symptom checking and triage tools in order to route patients to an
appropriate care setting.
27US Health Insurance Trends 2020
RISK CARVE-OUTS
As startups become more confident in their ability to drive down
costs for insurers, look for them to take on risk for insurers’ entire
populations in specific therapeutic areas and indications.
A carve-out is a contract where an insurer pays a third party healthcare
program a per-member-per-month (“PMPM” or “capitated”) rate for a
subset of the insurer’s members. In return, the third party program —
which may range from disease-specific healthcare programs to services
like dental care — covers care costs for that specific subset of care.
The US Centers for Medicare and Medicaid Services (CMS) and the
Department of Health and Human Services (HHS) announced 5 new
payment models to revamp primary care for Medicare last year, with
several models consisting of capitated monthly payments to physicians
for managing primary care for certain populations.
These carve-out agreements can be compelling propositions for
both sides:
•	 Insurers can offset some of their risk and reduce cost variability
•	 Third parties that believe their solutions can keep patient costs
below the capitated rate can boost their revenues
One area where startups are beginning to take on risk is Chronic
Kidney Disease (CKD). Patients with CKD experience declining kidney
functionality and often require dialysis several times each week.
Somatus, a startup which focuses on managing kidney disease in the
home, is working with Blue Cross Blue Shield of Tennessee in a total
cost-of-care population health agreement, where Somatus keeps some
of the savings it generates.
28US Health Insurance Trends 2020
Other areas where insurers have carved out risk include oncology and
musculoskeletal care.
As the healthcare sector continues to shift towards value-based
care, and digital health startups mature to the point where they are
comfortable projecting out expenses for entire patient populations, look
for insurers to carve out risk in new areas.
29US Health Insurance Trends 2020
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Health Insurance Trends 2020

  • 2. CB Insights is a tech market intelligence platform that analyzes millions of data points on venture capital, startups, patents, partnerships and news mentions to help you see tomorrow’s opportunities, today. WHAT IS CB INSIGHTS? CLICK HERE TO LEARN MORE
  • 3. 3US Health Insurance Trends 2020 Table of Contents CONTENTS NExTT framework 4 NECESSARY Health savings accounts 7 Medicare Advantage (MA) supplemental benefits 9 Self-insured employer experimentation 11 Payviders and verticalization 14 EXPERIMENTAL Blockchain 16 Health sharing ministries 18 TRANSITORY Big Tech inroads 19 Pricing transparency 21 THREATENING Social determinants of health (SDOH) 23 Digital front door 25 Risk carve-outs 27
  • 4. 4US Health Insurance Trends 2020 US Health Insurance Trends 2020 NExTT FRAMEWORK
  • 5. 5US Health Insurance Trends 2020 We evaluate each of these trends using the CB Insights NExTT framework. The NExTT framework educates businesses about emerging trends and guides their decisions in accordance with their comfort with risk. NExTT uses data-driven signals to evaluate technology, product, and business model trends from conception to maturity to broad adoption. The NExTT framework’s 2 dimensions: INDUSTRY ADOPTION (y-axis): Signals include momentum of startups in the space, media attention, customer adoption (partnerships, customer, licensing deals). MARKET STRENGTH (x-axis): Signals include market sizing forecasts, quality and number of investors and capital, investments in R&D, earnings transcript commentary, competitive intensity, incumbent deal making (M&A, strategic investments). NExTT Trends
  • 6. 6US Health Insurance Trends 2020 For many, health insurance is an enigma. Healthcare pricing is notoriously opaque, health plan acronyms seem to span the whole alphabet (HDHP, EPO, HMO), and navigating the industry requires a whole new vocabulary of specific, often unintuitive terms. Add in some complex economic concepts (like “moral hazard,” “quality- adjusted life years,” and “risk pooling”) and we get a market that impacts all but is understood by few. The industry sits at the crossroads of actuarial math, technology, policy, and consumerism — each of which have the potential to drastically impact the way healthcare is paid for. As US healthcare costs continue to skyrocket, and with life expectancy in the US decreasing for consecutive years, the conditions are ripe for big changes to how care is paid for and delivered. In addition to this, there are a number of macro trends that will necessitate changes to the US healthcare system. Between 2010 and 2030, the US population as a whole is expected to grow by around 40M. With over 10,000 baby boomers turning 65 each day, the United States currently lacks the infrastructure to care for this population in traditional settings like nursing homes and assisted living facilities. As a result, care will likely shift to new settings like the home. At the same time, tech giants like Apple, Google, and Amazon are dipping their toes into the insurance space, and companies are increasingly exploring health insurance applications of emerging technologies like blockchain and AI chatbots. As the negotiators and allocators of care, insurers are at the forefront of many changes in the healthcare industry. In this report, we dive into 11 key trends that will impact the US health insurance landscape over the next few years. What’s next for US health insurers? We looked across the industry to identify 11 of the biggest payer trends, from blockchain to digital front doors.
  • 7. 7US Health Insurance Trends 2020 HEALTH SAVINGS ACCOUNTS The health savings account industry is a big beneficiary of rising deductibles in employer-sponsored insurance. Health Savings Accounts (HSAs) are one of the more underappreciated tax-advantaged opportunities offered in the US today. These accounts allow individuals in qualified health plans, or plans with deductibles higher than a certain threshold, to contribute pre-tax money to an account for health expenses. With deductibles rising across employer plans, more plans are becoming eligible for HSAs: 23% of workers in 2019 had an HSA, compared to just 6% in 2009, according to the Kaiser Family Foundation employer health benefits survey. HSA owners can spend their account’s money on health-related expenses or keep the money invested in their accounts, earning interest. (Unlike a flexible health spending account (FSA), money in an HSA can roll over year-to-year.) HSA deposits are estimated to reach $75B in 2020, according to Denevir. Source: Denevir Necessary
  • 8. 8US Health Insurance Trends 2020 HSAs are often described as having a “triple tax advantage,” this is because: • Individuals can contribute pre-tax earnings without paying income taxes on a federal or state level • That money can be invested and grow on a tax-free basis • If applied to qualifying expenses, that money can be withdrawn tax-free ahead of retirement Three startups looking to modernize HSAs raised money in 2019: Bend Financial, Lively, and Starship. Each is attempting to bring the latest in fintech — such as robo advisers, fee-free transfers, and overflow investing — to take a piece of the large and growing HSA space. As millennials (the most active users of popular fintech platforms like Robinhood and Cash App) continue to accrue more wealth, and awareness grows of the potential benefits of HSAs, look for the HSA space to take off in the coming years.
  • 9. 9US Health Insurance Trends 2020 MEDICARE ADVANTAGE SUPPLEMENTAL BENEFITS Medicare Advantage insurers are offering new benefits in the hopes of attracting new members, improving outcomes, and cutting costs. There was a time when offering benefits like vision, hearing, and dental was an effective tactic for luring new members to Medicare Advantage (MA) plans. But with insurance giants seeing MA as a major growth area, and with 4 unicorn startups (Oscar, Clover, Bright, and Devoted) looking to take a piece of the market, basic benefits like these are becoming standard for insurers trying to win over new members. Insurers are beginning to offer new types of benefits to differentiate themselves, usually with one of two goals: attract new members or lower health costs. One benefit offering that aims to attract new members is UnitedHealth’s partnership with Warby Parker to offer discounted glasses. Other examples include insurers that offer discounted wearable devices like Apple Watches and FitBits, as well as free gym memberships. Source: Kaiser Family Foundation
  • 10. 10US Health Insurance Trends 2020 Moreover, many insurers are partnering with ride-hailing companies like Uber and Lyft to offer non-emergency medical transportation (NEMT) benefits to members. As government rules around supplemental benefits continue to encourage more experimentation, look for NEMT offerings to continue to grow. Another common type of MA benefit looks to lower overall health expenditures. Because only around 10% of MA members voluntarily change plans each year, insurers have an incentive to make longer term investments in member health. As a result, payers are investing in benefits related to chronic disease management and mental and behavioral health (by offering access to platforms like Talkspace), which they hope can provide a return on investment over the long term. Some of the common partners for these efforts include Livongo, Omada, and Uber.
  • 11. 11US Health Insurance Trends 2020 SELF-INSURED EMPLOYER EXPERIMENTATION With the opportunity to save money and improve employee efficiency and satisfaction, self-insured employers will continue to adopt new care models and technologies. A “self-insured” employer takes on insurance risk for its employee population. To accomplish this, it usually signs an “administrative services only” (ASO) contract with an insurance company and gets an insurance policy to cover the company in case its healthcare costs are unusually high in a given year. Under these ASO contracts, insurers typically build out a network on behalf of the self-insured employer and negotiate rates. Self-insured plans cover an estimated 94M employees in the US. Despite associated risks, we continue to see experimentation in the self-insured population, as employers seek to provide better care to their employees at lower costs. Self-insured employers can keep the savings they generate by reducing costs, can improve company efficiency by promoting healthier employees, and can use quality health benefits as a marketing tool to attract talent. Self-insured employers with broader healthcare aspirations can also use their employee population to test new approaches to care before rolling them out to the public. One company working on this is Walmart, which has established some unique programs to manage the health of its 1.5M US employees.
  • 12. 12US Health Insurance Trends 2020 For example, Walmart offers to pay the full cost to fly out its employees to receive complex care at national “centers of excellence” like Cleveland Clinic for cardiac surgery and Johns Hopkins for joint replacements. The retail giant also partnered with Embold Health to identify the best doctors for its employees in certain regions, and is testing out personal “care concierges” for some of its employees. Private companies are also raising funds to build out plans for self- insured employers. Health benefits platform Collective Health has raised $434M from investors including Google Ventures, NEA, and SoftBank.
  • 13. 13US Health Insurance Trends 2020 Employer-focused primary care group Paladina Health has raised $165M, while disease management platform Omada has raised $201M. Companies primarily serving the employer market have also seen IPOs in the past year, including One Medical, Livongo Health, and Progyny, and have shown positive ROIs for their customers. Accolade, a care navigation upstart that raised $215M from investors including Humana, Independence Blue Cross, McKesson Ventures, and Andreessen Horowitz, filed its S-1 in late February and disclosed close to $100M in revenue in the most recent fiscal year. A key self-insured employer experiment to watch is Haven, the collaboration between Amazon, JPMorgan, and Berkshire Hathaway to manage care and simplify coverage for their 1M+ combined employees. However, little has been made public about the partnership aside from some high-profile hires and a few plan offerings that include wellness incentives and have no deductibles. Separately, Amazon is offering home visits and telemedicine to employees in the Seattle area through Amazon Care. Going forward, look for employers to continue to experiment with new models of care for their employee populations
  • 14. 14US Health Insurance Trends 2020 PAYVIDERS AND VERTICALIZATION Many companies are betting that combining the roles of payers and providers can reduce costs and improve care outcomes. Over the last few years, the traditionally distinct lines between healthcare payers’ (insurers) and providers’ functions have blurred. Instead, we’re beginning to see providers take on more risk, while payers are increasingly buying up providers and steering members to their own facilities. In a value-based healthcare system, this verticalization is rational, as it aligns parties to deliver quality care at lower costs. (In contrast, the traditional fee-for-service system incentivizes volume over quality.) Source: Chilmark Research Startup insurer Devoted Health has raised almost $369M, most recently
  • 15. 15US Health Insurance Trends 2020 at a $1.8B valuation, to build out a Medicare Advantage offering with this “payvider” model in place. While Devoted’s verticalization focuses primarily on primary care, Humana has taken the approach to post- acute care — such as rehabilitation or palliative services. Over the last few years, the insurance giant acquired a portion of Kindred at Home, the country’s largest home health and hospice provider, and bought hospice care provider Curo Health Services with the aim of improving outcomes for its patient population. Humana also recently partnered with private equity firm WCAS, a partner in the Kindred deal, to invest approximately $600M into a new primary care joint venture that could more than double its primary care footprint. Blue Cross Blue Shield plans across the US have also opened their own clinics. For instance, BCBS of Texas, Florida Blue, and BCBS of Tennessee have opened medical centers in partnership with Sanitas Medical to deliver services like primary care, urgent care, and diagnostic imaging. At the same time, providers are seeing an opportunity to benefit from the savings that they can generate by taking on insurance risk. Some of the country’s most prominent health systems — including the Mayo Clinic and the Cleveland Clinic — are now bearing risk for portions of the patient populations in their surrounding areas.
  • 16. 16US Health Insurance Trends 2020 Experimental BLOCKCHAIN Incumbents have begun to research applications of blockchain technology in healthcare. Two large partnerships have formed to use blockchain technology to help solve complex healthcare problems. The first, led by IBM, includes Anthem, CVS, HCSC, BHI, and PNC. The second, called Synaptic Health Alliance, includes United, Optum, Humana, CVS, Ascension, MultiPlan, and Quest Diagnostics. One early goal for each collaboration is to establish live directories of in-network providers on the blockchain, with the aim of allowing insurers to update their networks in real time for members to access. This has historically been a pain point for patients, who have had difficulty keeping track of when providers join or leave their networks.
  • 17. 17US Health Insurance Trends 2020 Another potential application for blockchain is tracking medications. The Drug Supply Chain Security Act states that drugs will need to become traceable throughout the pharmaceutical supply chain, from the manufacturer all the way to the end-user. Similar to food and grocery companies using blockchain technology to drive food safety across the supply chain, blockchain technology has the potential to be a significant aspect of future drug tracking solutions.
  • 18. 18US Health Insurance Trends 2020 HEALTH SHARING MINISTRIES Health Sharing Ministries have ballooned in popularity, but may be susceptible to policy changes and economic downturns. Health sharing ministries are growing fast, going from covering 160,000 people in 2014 to more than 1M today, according to the Alliance for Health Care Sharing Ministries. Health sharing ministries are cost-sharing organizations for individuals that "have a shared common ethical or religious belief." These plans, which tend to be much cheaper than traditional health insurance, require relying on other members to send payments to help cover healthcare bills after care is provided. The three biggest ministries are Samaritan, Medi-Share, and Christian Healthcare Ministries. These plans are not regulated in the same way as traditional health insurance. For example, they don't have to keep reserves to pay future claims, don't have to require out of-pocket maximums, often don’t accept new members with pre-existing conditions, and can deny coverage if they deem a member’s expenses or behavior immoral. We're seeing many different insurance products that are purposefully being structured to attract young, healthy people that don't have a ton of money to spend, but see their health insurance premiums slowly rising. Short-term plans, self-insured plans, health sharing ministries, and more are all approaches that young people are using to find cheaper coverage. However, these plans work until they don't — like when people have serious healthcare issues, or when the economy takes a tumble.
  • 19. 19US Health Insurance Trends 2020 Transitory BIG TECH INROADS Big tech companies are starting to dabble in areas related to health insurance. Look for that trend to continue in 2020 as tech giants look to recoup the savings their technologies generate for the health system. Big tech companies are picking up steam in the healthcare space, from Google in devices and data, to Amazon in the pharmaceutical and hospital supply chains, to Apple in personal data and wearables. And now, tech giants are venturing into health insurance through partnerships and investments. Of the big tech players, Google has made the most moves in the insurance space thus far. Its $375M investment in Oscar Health in August 2018 reportedly brought its stake in Oscar to around 10%, including investments from other Google entities in previous rounds. It also currently holds positions in Clover Health, an insurance startup in the Medicare Advantage space, and Collective Health, which acts as a carrier for self-insured employers. Amazon has made moves in the health insurance space as well. The retail giant now accepts HSAs and FSAs for health-related purchases on its site. It is also working with insurer Cigna to develop an app for its now HIPAA-compliant Alexa devices, and has partnered with JPMorgan and Berkshire Hathaway on an initiative called Haven to manage employee health (more on Haven in the self-insured employer section). Finally, Amazon and Blue Cross Blue Shield of Massachusetts have announced that PillPack by Amazon Pharmacy has been integrated into the insurer’s member app.
  • 20. 20US Health Insurance Trends 2020 Apple’s entrance into the health insurance space has revolved around the Apple Watch. The company has partnered with a number of insurers, including United and Devoted Health, to offer subsidized watches to members with the aim of incentivizing wellness and monitoring health. Apple has also partnered with Aetna: the two companies worked together on an app called Attain, which provides “nudges” towards healthy behaviors and encourages members to be active. Finally, Apple’s health kit and personal electronic medical record (EMR) systems position it well to manage data on behalf of insurer partners. But big tech has only scratched the surface of health insurance and may soon move to take on insurance risk. To do this, we may see Google, Apple, or Amazon start, partner with, or acquire a health plan in the near future.
  • 21. 21US Health Insurance Trends 2020 PRICING TRANSPARENCY Macro consumer and political trends are pushing the healthcare industry to be more transparent about pricing. One central goal of pricing disclosure policies is to make healthcare a more competitive marketplace where consumers could shop around based on price. In 2019, the Trump administration announced a policy that would require hospitals to disclose their negotiated pricing for common services on an publicly available online tool, and also hinted at the potential to require the same of insurers. But beyond this legislation, some players in the healthcare industry are independently moving towards more transparency. As deductibles continue to rise and patients pay for increasing amounts of care out-of-pocket, many patients are agitated about the variability in pricing for commoditized medical services. In response, some big players, like CVS and Walmart, have started to list prices on their websites for common healthcare services available at their clinics. Several startups are also aiming to simplify healthcare pricing for their consumers. GoodRx, last valued at $2.8B, is looking to increase price transparency for cash-paying customers who buy prescription drugs. The company aggregates pricing for drugs at local pharmacies and directs its customers towards the lowest cost options. This works especially well because prescription drugs are commoditized — customers receive the same product regardless of which pharmacy they get their drugs from.
  • 22. 22US Health Insurance Trends 2020 Slingshot Health is creating a marketplace for less commoditized services like medical appointments and procedures. The startup uses a reverse auction process, in which a patient can input the services they are looking for and their availability, and providers compete by bidding the lowest price they are willing to accept for the service. Other startups working to increase transparency in the system are Healthcare Bluebook, Carrum Health, and MDSave. Source: Bind Meanwhile, startup Bind is looking to rebuild the entire health insurance offering with transparency at its core. The company eliminates deductibles and co-insurance in favor of transparent prices for members. Insurance giant UnitedHealth, an investor in Bind, seems to be seeing traction in the company’s model and referenced Bind three times on a recent earnings call, according to CB Insights’ earnings transcript analysis tool.
  • 23. 23US Health Insurance Trends 2020 Threatening SOCIAL DETERMINANTS OF HEALTH (SDOH) Insurers are beginning to realize that social determinants may have more of an impact on health outcomes than care itself. Social determinants of health (SDOH) was one of the buzziest terms in healthcare in 2019. The term came up on earnings calls more than twice as many times in 2019 than in all prior years combined, while news mentions of SDOH have skyrocketed since 2015. SDOH refers to the conditions “in which people are born, grow, live, work and age that shape health,” according to the Kaiser Family Foundation. Targeted investments in these areas — which include housing, food security, education, and community — are one way healthcare stakeholders are looking to lower costs and improve healthcare outcomes. Many communities already have programs in place that work to tackle these issues.
  • 24. 24US Health Insurance Trends 2020 Companies like Unite Us and WellFrame are working on solutions that direct individuals towards available resources, including food kitchens and free legal assistance. Investors and partners for the two startups include payers such as Blue Cross Blue Shield Venture Partners, CVS Health, and Kaiser Permanente. Going forward, we may start to see the conversation shift to structural determinants of health as well. Structural determinants of health refers to policies and infrastructure in place that ultimately feed into these social determinants, like Medicaid expansion and laws surrounding HIV status disclosure.
  • 25. 25US Health Insurance Trends 2020 DIGITAL FRONT DOOR Incumbents and newcomers alike are fighting to be patients’ first interaction with the increasingly digital healthcare system. One way payers are aiming to lower costs and improve outcomes for their members is to be the first point of contact for people interacting with the healthcare system. From there, payers can navigate members to the optimal provider and care settings for a specific condition. For example, a patient with cold symptoms could be sent to be treated by a nurse in an urgent care center instead of a doctor in an emergency room. This approach can help members avoid costly emergency room visits for minor ailments like sore throats and small cuts. Healthcare players are working on these types of solutions through each of the build, buy, and partner pathways. Oscar, for example, has built an app in-house that, together with its website, serves as the company’s digital front door. The company claims 41% of its members are monthly active users on either its app or its website, and reports that 63% of members’ healthcare system interactions are virtual.
  • 26. 26US Health Insurance Trends 2020 Source: Oscar Health Anthem, meanwhile, is partnering to establish a digital front door for its members. The insurance giant is working with a startup called K Health to develop an app for its members. The app, called CareSpree, incorporates the startup’s AI-powered chatbot to show patients common diagnoses for prior users who have experienced similar symptoms. The app then facilitates telehealth visits with doctors for interested users. Amazon appears to be taking the “buy” route to the digital front door. The tech giant recently acquired Health Navigator, which provides online symptom checking and triage tools in order to route patients to an appropriate care setting.
  • 27. 27US Health Insurance Trends 2020 RISK CARVE-OUTS As startups become more confident in their ability to drive down costs for insurers, look for them to take on risk for insurers’ entire populations in specific therapeutic areas and indications. A carve-out is a contract where an insurer pays a third party healthcare program a per-member-per-month (“PMPM” or “capitated”) rate for a subset of the insurer’s members. In return, the third party program — which may range from disease-specific healthcare programs to services like dental care — covers care costs for that specific subset of care. The US Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services (HHS) announced 5 new payment models to revamp primary care for Medicare last year, with several models consisting of capitated monthly payments to physicians for managing primary care for certain populations. These carve-out agreements can be compelling propositions for both sides: • Insurers can offset some of their risk and reduce cost variability • Third parties that believe their solutions can keep patient costs below the capitated rate can boost their revenues One area where startups are beginning to take on risk is Chronic Kidney Disease (CKD). Patients with CKD experience declining kidney functionality and often require dialysis several times each week. Somatus, a startup which focuses on managing kidney disease in the home, is working with Blue Cross Blue Shield of Tennessee in a total cost-of-care population health agreement, where Somatus keeps some of the savings it generates.
  • 28. 28US Health Insurance Trends 2020 Other areas where insurers have carved out risk include oncology and musculoskeletal care. As the healthcare sector continues to shift towards value-based care, and digital health startups mature to the point where they are comfortable projecting out expenses for entire patient populations, look for insurers to carve out risk in new areas.
  • 29. 29US Health Insurance Trends 2020 The CB Insights platform has the underlying data included in this report WHERE IS ALL THIS DATA FROM? CLICK HERE TO SIGN UP FOR FREE