U.S. Business Process As A Service In Healthcare Payers Market Size, Share & Trends Analysis Report By Solution Coverage, By Buyer Type, By Value Chain Processes, By Buyer Size, And Segment Forecasts, 2022 - 2030

Report Overview

The U.S. business process as a service in healthcare payers market size was estimated at USD 5.6 billion in 2021 and is expected to expand at a compound annual growth rate (CAGR) of 6.0 % from 2022 to 2030. The U.S. spends over USD 3.8 trillion on healthcare, roughly twice as much as any other major international economy, due to the complexity and inefficiency of its healthcare system. BPaaS engagements contribute significantly to healthcare payer business process outsourcing revenue, which is likely to drive the industry’s growth.

Furthermore, with an average operating margin of only 4.3%, well below for-profit health institutions' 6.1% or pharmaceutical corporations' 19.4%, payers are the group most adversely affected by inefficiencies in the healthcare system. Because the traditional IT/BPO outsourcing model has fallen short in addressing these issues, payers are now turning to the cutting-edge business process as a services (BPaaS) outsourcing model, which offers them platform-based modernization, ultimately leading to industry expansion over the forecast period.

The market is likely to be impacted by the COVID-19 pandemic, expanding healthcare consumerism, changing regulations, and the shift to value-based healthcare. Due to these challenges and declining margins, healthcare providers are being compelled to think about different game plans, such as BPaaS, to improve the patient experience, which is eventually driving the market's revenue growth due to the rise in demand and acceptance of the BPaaS system.

The COVID-19 pandemic has greatly increased the financial, regulatory, and technology challenges that healthcare payers currently confront. The pandemic has improved payers' cash flow in the short term, but it has also brought about major operational and market changes for which payers must get prepared. For instance, after 2 years of decline, U.S. states anticipate an 8.2% growth in Medicaid membership in 2021, according to an article released by Everest Group in 2021. The exchange market is also anticipated to expand as a result of payers including United Healthcare, Anthem, Centene, and Oscar Health reviving their interest in this market due to changes in COVID-19's enrollment patterns.

Over the forecast period, support for the expansion of the BPaaS market is expected to increase as a result of these changes and the speed at which they are being implemented, which is making it harder for payers to scale their operations by shifting industry requirements. Additionally, the Affordable Care Act and the Centers for Medicare and Medicaid are driving regulations and payment/reimbursement practices, causing more and more conversations. These pressures, combined with the possibility of margins contracting in 2021, make this the ideal time for payers to assess options for profitable growth and improved agility.

The ongoing COVID-19 pandemic has created a situation where plan members and healthcare providers are open and able to change, and health insurers now have some financial wiggle room. The first strategy payers should consider is a business process as a service (BPaaS), whereby increasing its adoption is anticipated to expand the industry’s growth over the forecast period.

Solution Coverage Insights

Best-of-breed solutions are catching up as a result of increased commercial SaaS use, even though traditional BPaaS solutions have gained more momentum among businesses. Best-of-breed BPaaS is predicted to grow at a CAGR of 9.4% over the forecast period.

Best-of-breed BPaaS models would be made possible by factors including expanding the availability of a BPS partner ecosystem for technological platforms and advancements in data security and compliance standards. The BPS horizontals, such as HRO, where third-party solutions like workday and success factors are mature and have a high adoption rate, are where this tendency is particularly pronounced.

Traditional BPaaS and Best-of-breed BPaaS Insights

For healthcare payers, in both the segments-end-to-end traditional and best-of-breed model accounts for the majority of the shares and it is anticipated to grow at a CAGR of 5.0%, and 9.4% respectively. This is majorly driven by the fact that a single provider offers an end-to-end one-stop BPaaS solution, which acts as the most popular choice among the payers. are catching up as a result of increased commercial SaaS use, even though traditional BPaaS solutions have gained more momentum among businesses. Best-of-breed BPaaS is predicted to grow at a CAGR of 9.4% in the forecast period.

Buyer Type Insights

Over the forecast period, it is anticipated that government buyers would witness a CAGR of 5.7%. Government plans have historically been the main buyer sector for BPaaS due to the modular implementations of Medicaid Management Information Systems (MMIS). U.S. states have entrusted service providers with the design, development, and implementation of MMIS platforms as well as the use and maintenance of such platforms. As CMS advances the modularity agenda, more states are modernizing their outdated monolithic systems and progressively moving to the as-a-service paradigm.

These states frequently make use of BPaaS products from service providers (third-party liability) for administrative modules such as claims processing, provider management, and financial support services (third-party liability). According to an article published by the Everest group in 2021, states like Wyoming and Montana have begun to use the BPaaS idea for critical medical processes, including care management.

Value Chain Processes And Buyer Size Insights

By value chain processes, BPaaS has seen early adoption among administrative procedures, with the following significant cases:

A)   A significant US health plan has agreed to a contract with a BPS service provider in the healthcare industry to use the latter's BPaaS solution for the full range of claims administration, from claims processing and validation to payments and adjudication.

B)   A midsized health plan uses BPaaS to streamline its encounter and claims processing.

C)   One of the biggest Blues plans used BPaaS to boost the number of people enrolled in Medicare Advantage. It used BPaaS to comply with CMS regulations and raise the STAR ratings of its MA plan.

The most important point to take away from these use cases is that while BPaaS adoption is increasing across administrative processes, most payers have not fully realized the benefits of BPaaS by integrating it throughout the value chain.

Payers are not implementing BPaaS across the entire spectrum of activities, not even for administrative processes that use it. For instance, BPaaS deployment and process optimization across the value chain, including member engagement, risk adjustment, and STAR rating assistance, would be required to achieve larger enrollment in MA plans.

Based on industry understanding, it is projected that BPaas adoption will lead to a dominance among Small to Midsize buyers, holding more than 70% of the revenue share during the forecast period. Additionally, member management and care management are predicted to grow at CAGRs of 6.9% and 6.0%, respectively, throughout the forecast period, and will be the processes that generate the majority of this revenue in terms of the value chain.

Commercial Buyers Insights

While government buyers account for a majority of the healthcare payer BPaaS market, the BPaaS adoption is driven by regulatory push or the CMS mandate and not the states’ intent to achieve operational and technological efficiencies. In contrast, the commercial payer segment is rapidly adopting the BPaaS approach. Over the forecast period, it is anticipated that Medicare advantage would witness a CAGR of 7.3% during the forecast period.

Following COVID-19, the already increasing MA and Managed Medicaid enrollment received an additional boost. According to a survey by Medicare Advantage Plans, 45% of Medicare recipients transfer from an original Medicare plan to an MA plan in 2021. Additionally, the 21^st Century Cures Act is anticipated to result in a significant increase in ESRD patients in MA plans.

Moreover, from March 2020 through December 2020, Managed Medicaid membership rose to 15.2%, maintaining the trend of rising Medicaid participation, according to a 2021 article from Accenture. Additionally, it is estimated that during the projected time, BPaaS use will increase at a 6.8% rate in managed Medicaid.

Key Companies & Market Share Insights

Companies are stepping up their efforts to maintain their position in the competitively escalating market by introducing new products. For instance, Cognizant, which has a dominant position in the market for service providers to U.S. healthcare payers due to its industry knowledge, tools, cloud, and digital portfolio, invested USD 120 million in platform R&D in 2020 to support its BPaaS solutions. Additionally, Legato Health Technologies introduced a product Business Process as a Service (BPaaS) offering in 2021, enhancing its current portfolio of business process and technology services to better serve the requirements of health plans of all sizes. 

Furthermore, companies that are primarily involved in this market and have strong BPaaS product offerings have increased their collaborations with providers to maintain their revenue share and support their U.S. operations. These partnerships enable partners to jointly develop cutting-edge programs, solutions, and initiatives for the benefit of patients and the healthcare system. Genpact, for instance, offers payers a strong BPaaS offering that grew out of its BPO legacy, an increasing emphasis on digital transformation skills, and in-depth domain understanding in the healthcare sector. In January 2021, it bought Enquero, a small California-based company that provides services for data engineering and data-led digital transformation, to strengthen its U.S. operations.

Moreover, the market players that already have a large user base are driven to maintain their market revenue share due to the increased need for Value-Based Healthcare systems and the payers' increasing need for web-enabled services to sustain business processes. For instance, NTT DATA has over 50 customers for its Digital BPaaS for Health Plans, which includes multistate, state, national, and local plans. The payers with 50,000-300,000 members in the Medicare, Medicaid, and Medicare Advantage divisions as well as those with 300,000 or more members in a commercial line of business constitute its right balance, ultimately enabling it to maintain its existing notable market share.Some prominent players in the U.S. business process as a service (BPaaS) in healthcare payers market include:

• Accenture

• Cognizant

• HCL

• IBM

• Infosys

• NTT DATA

• Optum

• TCS

• UST

• Wipro

• EXL

• Softheon

• Genpact

• Change Healthcare

• Firstsource

• Celegence

U.S. Business Process As A Service In Healthcare Payers Market Report Scope

U.S. Business Process As A Service In Healthcare Payers Market Segmentation

This report forecasts revenue growth at the country level and provides an analysis of the latest industry trends in each of the sub-segments from 2017 to 2030. For this study, Grand View Research has segmented the U.S. Business Process as a Service (BPaaS) in healthcare payers market report based on solution coverage, buyer type, value chain processes, and buyer size:

• Solution Coverage Outlook (Revenue, USD Billion, 2017 - 2030)

  • Traditional BPaaS

    • End-to-end traditional BPaaS

    • Process-specific traditional BPaaS

  • Best-of-breed BPaaS

    • End-to-end best-of-breed BPaaS

    • Process-specific best-of-breed BPaaS

• Buyer type Outlook (Revenue, USD Billion, 2017 - 2030)

  • Government buyers

  • Commercial buyers

    • Medicare Advantage

    • Managed Medicaid

    • Individual health plan

    • Employer-sponsored health plan

• Value Chain Processes Outlook (Revenue, USD Billion, 2017 - 2030)

  • Claims Management

  • Member Engagement

  • Care Management

  • Others (Product development, Network Management, Risk & Compliance)

• Buyer Size (Revenue, USD Billion, 2017 - 2030)

  • Small buyers

  • Midsized buyers

  • Large buyers