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Health Insurance Information Technology: US Overview and Outlook, 2014-2020

Key Findings—Study Highlights

Today, healthcare payers are grappling with a number of significant challenges that are upending their traditional business models and operational processes.

- A plethora of new regulations and compliance obligations as a result of the Affordable Care Act (ACA); continued cost inflation driven by healthcare providers, pharmaceutical companies, and technology vendors; consolidating providers and large employers getting tougher on payer contract negotiations; and the rise of individual consumers demanding a higher level of service at lower premiums are just some of issues causing real angst among payers.

- Added to the mix is the new experimentation with changing reimbursement models and risk-sharing arrangements which will require new ways of working with and sharing information with healthcare providers.

- To tackle these many challenges, health plans are actively looking at information technology as a lever of operational efficiency and transformational change, with spending priorities focused on new tools for analytics, consumer engagement, and population health/care management.

- IT vendors serve a central role in helping payers to better leverage their vast claims data resources, bringing these data together with clinical, financial, socio-economic, and other data generated across the health ecosystem to create robust data sets that can be used to improve the quality and efficiency of healthcare and create new innovative tools to engage consumers.

- While total IT spend for the health insurance industry is expected to grow in line with premium growth reflecting a surge of new covered lives due to ACA, Frost & Sullivan predicts that the industry standard percentage of total premium devoted to IT will not significantly increase overall due to growing margin pressures and the need to contain rising administrative costs. Rather, the allocation of spend among various IT segments (infrastructure/hardware, core administrative systems, BI/analytics, and consumer engagement) will shift to focus on new business priorities arising from shift to consumer focus.

Key Questions This Study Will Answer

- How does the US health insurance system operate and what is the role of various information technology (IT) products and services that are deployed within the system?
- What are the market-shifting macro trends impacting the health insurance industry today?
- What are the specific drivers and restraints impacting the market for IT solutions used in US health insurance companies over the next 5 to 6 years?
- What is the 6-year revenue outlook for IT solutions deployed by health insurance organizations?
- What are the key competitive characteristics for IT vendors serving the market?

Table Of Contents

Health Insurance Information Technology: US Overview and Outlook, 2014-2020 
Table Of Contents
1 EXECUTIVE SUMMARY

Executive Summary
1. Key Findings—Study Highlights
2. Key Findings—Study Highlights
3. Key Findings
4. Scope and Segmentation
5. Scope and Segmentation
6. Key Questions This Study Will Answer
7. Measurements
8. CEO's Perspective
9. Executive Summary—3 Big Predictions

2 MARKET BACKGROUND

Market Background
1. Snapshot of the Health Insurance Industry in 2014
2. Health Insurance Industry Fundamentals
3. IT Solutions Used by Health Insurance Organizations
4. Market Scope and Definition for Health Insurance IT
5. Market Distribution Structure for IT Solutions Used by Health Insurance Organizations

3 INTRODUCTION TO THE HEALTH INSURANCE INDUSTRY

Introduction to the Health Insurance Industry
1. Introduction to Insurance
2. What is Health Insurance?
3. Key Functions and Core Processes of Health Insurance Organizations
4. How Health Insurance Fits in With Funding for Healthcare Services
5. Public Versus Private Health Insurance
6. Definitions of Common Types of Health Insurance Plans
7. Definitions of Types of Managed Care Organizations
8. Key Market Categories for Health Insurance Plans
9. Macro Conditions Impacting Health Insurance Organizations
10. Macro Conditions Impacting Health Insurance Organizations
11. Summary of Enveloping Elements Impacting Health Insurers
12. Winning Strategies to Drive Business Value

4 THE AFFORDABLE CARE ACT AND THE HEALTH INSURANCE INDUSTRY

The Affordable Care Act and the Health Insurance Industry
1. The Patient Protection and Affordable Care Act
2. Timeline of Key Events for the Affordable Care Act
3. How is ACA Funded?
4. Estimated Distribution of ACA Funding Sources Over Time
5. Key Health Insurance Market Reforms Due to ACA
6. The Impact of ACA Medical Loss Ratio
7. Premium Distribution Based on ACA-MLR Rule
8. Ten Essential Health Benefits of ACA
9. ACA Online Insurance Exchanges
10. The Key ACA Insurance Plans

5 TRENDS IN HEALTH INSURANCE EXPENDITURES

Trends in Health Insurance Expenditures
1. Health Insurance Coverage—Snapshot of US Population
2. Government Definitions for Health Insurance and Payment Categories of National Health Insurance Expenditures
3. Trends in National Health Expenditures
4. Historical and Projected Average Annual Growth Rates for Per Capita Health Spend
5. National Health Expenditures by Type of Service
6. Percentage Distribution of National Health Expenditures for Public and Private Health Insurance
7. National Health Expenditures for Public and Private Health Insurance
8. Projected Average Annual Growth for Select NHE Categories Compared to National Gross Domestic Product (GDP)
9. Projected Average Annual Growth in Health Insurance Spend by Select Categories

6 HEALTH INSURANCE AND INFORMATION TECHNOLOGY

Health Insurance and Information Technology
1. Market Segmentation—Health Insurance IT
2. Core IT Architecture
3. Market Penetration for Software Applications
4. Select IT Vendors Serving the Health Insurance Industry
5. IT Infrastructure/Hardware
6. Core Administrative Systems
7. BI/Analytics
8. Consumer Engagement
9. Health Insurers View IT Investments as Key to Transformation, Growth, and Innovation
10. Top Areas of IT Investments for Health Plans
11. IT Priorities for Next Generation Health Plans: Where Vendors Need to Focus

7 TOTAL HEALTH INSURANCE IT MARKET—DRIVERS, RESTRAINTS, AND TRENDS

Total Health Insurance IT Market—Drivers, Restraints, and Trends
1. The Big Picture: Macro Forces Impacting the Health Insurance Industry
2. Key IT and Business Challenges Facing Health Insurance
3. Market Drivers
4. Market Restraints
5. Impact Mapping of Drivers and Restraints for the US Health Insurance IT Market

8 TOTAL HEALTH INSURANCE IT MARKET—REVENUE FORECAST AND TRENDS

Total Health Insurance IT Market—Revenue Forecast and Trends
1. Measurements
2. Forecast Assumptions and Definitions
3. Forecast Methodology
4. Total Health Insurance IT—Revenue Forecast
5. Total Market Revenue Forecast Discussion
6. Total Health Insurance IT—Percent Revenue Forecast by Segment
7. Revenue Forecast by Market Segment

9 REVENUE FORECAST AND TRENDS—MARKET SEGMENTS

Revenue Forecast and Trends—Market Segments
1. Measurements—IT Infrastructure/Hardware Segment
2. Revenue Forecast—IT Infrastructure/Hardware Segment
3. Discussion of Forecast Assumptions—IT Infrastructure/Hardware Segment
4. Measurements—Core Administrative Systems Segment
5. Revenue Forecast—Core Administrative Systems Segment
6. Discussion of Forecast Assumptions—Core Administrative Systems Segment
7. Measurements—BI/Analytics Segment
8. Revenue Forecast—Health Insurance IT, BI/Analytics Segment
9. Discussion of Forecast Assumptions—BI/Analytics Segment
10. Measurements—Consumer Engagement Segment
11. Revenue Forecast—Health Insurance IT, Consumer Engagement Segment
12. Discussion of Forecast Assumptions—Health Insurance IT, Consumer Engagement Segment

10 COMPETITIVE ENVIRONMENT

Competitive Environment
1. Competitive Market Forces Impacting Payer IT Vendors
2. Competitive Market Structure
3. Competitive Market Structure
4. Competitive Market Structure
5. Competitive Market Structure
6. Recent Notable Deals
7. Recent Notable Deals
8. Recent Notable Deals
9. Recent Notable Deals
10. Select Vendors and Products
11. Select Vendors and Products
12. Select Vendors and Products
13. Select Vendors and Products
14. Select Vendors and Products
15. Select Vendors and Products

11 THE LAST WORD

The Last Word
1. 3 Big Predictions
2. Legal Disclaimer

12 APPENDIX

Appendix
1. Definition of Select Terms Related to Health Insurance
2. Definition of Select Terms Related to Health Insurance
3. Definition of Select Terms Related to Health Insurance
4. Definition of Select Terms Related to Health Insurance
5. Definition of Select Terms Related to Health Insurance
6. Summary of Select Provisions of the ACA Impacting the Health Insurance Industry
7. Summary of Select Provisions of the ACA Impacting the Health Insurance Industry
8. Summary of Select Provisions of the ACA Impacting the Health Insurance Industry
9. US Health and Medical Insurance Carriers—Historical Statistics
10. Top Health Insurance Companies by Net Premium Written
11. Top Health Insurance Companies by Net Premium Written
12. Top Health Insurance Companies by Total Enrollment
13. Top Health Insurance Companies by Total Enrollment
14. Methodology
15. Sources
16. Sources
17. Learn More—Next Steps

List of Exhibits


Health Insurance IT: Frost and Sullivan Research Methodology, US, 2015
Health Insurance IT: Percentage Revenue Allocation by Market Segment, US, 2014
Health Insurance IT: Market Engineering Measurements, US, 2014
Health Insurance IT: Estimated Percentage of Total IT Spend for Products Versus Services, US, 2014
Health Insurance IT: Estimated Penetration of Software Applications, US, 2014
Total Health Insurance IT Market: Distribution Structure, US, 2015
Health Insurance IT: Public Versus Private Health Insurance, US, 2014
Health Insurance IT: Estimated Distribution of ACA Funding Sources Over Time, US, 2013-2022
Health Insurance IT: Health Insurance Coverage by Type of Health Insurance, US, 2013 and 2014
Health Insurance IT: NHE Payment Categories, US, 2014
Health Insurance IT: Average Annual Growth Rate of Health Spend Per Capita, US, 1970's-2024
Health Insurance IT: Average Annual Growth Rate of Health Spend Per Capita, US, 1970's-2024
Health Insurance IT: National Health Expenditures and Growth Forecast by Select Service Type, US, 2014 and 2020
Health Insurance IT: Projected Percentage Distribution of National Health Expenditures by Source of Funds, US, 2014 and 2020
Health Insurance IT: Projected National Health Expenditures for Public and Private Health Insurance, US, 2014 and 2020
Health Insurance IT: Projected Average Annual Growth for GDP and Select NHE Categories, US, 2014 and 2020
Health Insurance IT: Projected Average Annual Growth in Select Health Insurance Spend Categories, US, 2014 and 2020
Health Insurance IT: Market Segmentation, US, 2015
Health Insurance IT: Core IT Architecture, US, 2015
Total Health Insurance IT Market: Key Drivers, US, 2015-2020
Total Health Insurance IT Market: Key Restraints, US, 2015-2020
Total Health Insurance IT Market: Impact of Drivers and Restraints, US, 2015-2020
Total Health Insurance IT: Revenue Forecast, US, 2014-2020
Total Health Insurance IT: Percent Revenue Forecast by Segment, US, 2014-2020
Total Health Insurance IT: Revenue Forecast by Segment, US, 2014-2020
Health Insurance IT, IT/Infrastructure/Hardware Segment: Market Engineering Measurements, US, 2014
Health Insurance IT, IT Infrastructure/Hardware Segment: Revenue Forecast, US, 2014-2020
Health Insurance IT, IT Infrastructure/Hardware Segment: Revenue Forecast and Percentage Total Revenue, US, 2014 and 2020
Health Insurance IT, Core Administrative Systems Segment: Market Engineering Measurements, US, 2014
Health Insurance IT, Core Administrative Systems Segment: Revenue Forecast, US, 2014-2020
Health Insurance IT, Core Administrative Systems Segment: Revenue Forecast and Percentage Total Revenue, US, 2014 and 2020
Health Insurance IT, BI/Analytics Segment: Market Engineering Measurements, US, 2014
Health Insurance IT, BI/Analytics Segment: Revenue Forecast, US, 2014-2020
Health Insurance IT, BI/Analytics Segment: Revenue Forecast and Percentage Total Revenue, US, 2014 and 2020
Health Insurance IT, Consumer Engagement Segment: Market Engineering Measurements, US, 2014
Health Insurance IT, Consumer Engagement Segment: Revenue Forecast, US, 2014-2020
Health Insurance IT, Consumer Engagement Segment: Revenue Forecast and Percentage Total Revenue, US, 2014 and 2020
Health Insurance IT: Competitive Market Structure, US, 2014
Health Insurance IT: Notable Industry Deals, US, 2015
Health Insurance IT: Select Vendors and Products, US, 2015
Health Insurance IT: Definitions for Select Health Insurance Terms, US, 2015
Health Insurance IT: Select Provisions of the Patient Protection and Affordable Care Act (P.L. 111-148) Impacting the Health Insurance Industry, US, 2015
Health Insurance IT: Historical Statistics for Health and Medical Insurance Carriers , US, 1997, 2002, 2007, and 2012
Health Insurance IT: Top 20 Health Insurance Companies by Net Premiums Written, US, 2014
Health Insurance IT: Top 20 Health Insurance Companies by Total Enrollment, US, 2014






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