Cooperatives Being Pushed as an Alternative to a Government Plan
There are a number of business questions that these healthcare cooperatives will need to answer to survive and succeed. And each of these questions will require some form of business intelligence.
Getting capital and making wise investment decisions. They will likely be receiving seed money from a variety of governmental agencies, in a variety of forms, and earmarked for a variety of investment purposes. This requires sophisticated, wide-ranging analytical capabilities.
Negotiating favorable rates with providers. Cooperatives will have to bargain aggressively with hospitals and physician groups to negotiate favorable rates. They will be at a disadvantage compared with public payers such as Medicare, which enjoys reimbursement rates for doctors and hospitals set by federal law. As one might imagine, they will meet with opposition from providers. After all, a payer’s cost is a provider’s revenue.
Enrolling enough people to achieve critical mass. In order to obtain a large enough market share to survive, cooperatives will need to analyze their offerings, especially to break into markets where insurers are very well established.
Determining what services to offer, and why. As the article states, many will be integrated medical systems, which means that they will have to analyze a wide variety of revenue types, cost structures and operating models. Many will employ physicians and own healthcare facilities and supporting businesses (e.g. labs, pharmacies, etc.). All of these require different types of analytical models and applications.
Evaluating performance of partners. Cooperatives won’t have the ability to piggyback onto existing government institutions, so they will need to form partnerships with other cooperatives on a state or regional basis. Plus, they will need to work with a variety of other organizations, public and private.
Supporting member and public reporting. They will be owned by policyholders like mutual life insurance companies and by consumers, who will do comparison shopping.
Pricing, rating and determining eligibility effectively. In order to keep members’ premiums competitive, and at the same time serve their members’ coverage needs profitably, they will have to support complicated actuarial and eligibility models.
Applying lessons from other types of cooperatives. Cooperatives’ boards will require them to learn and apply best practices from other types of cooperatives, such as dairy, rural power, farm supply and retail cooperatives. In addition, they will need to understand the processes of models from major healthcare organizations such as HealthPartners and Group Health Cooperative. They will also have to integrate their services with existing informal cooperatives that exist across the U.S. and the rest of the world, especially in large ethnic communities.
Supporting regulatory compliance reporting. This will be a regulated marketplace, so compliance reporting will be required. Business intelligence can help.
Evaluating and defending options for evolution of the business model. Like Blue Cross and Blue Shield plans and other healthcare organizations that began as consumer cooperatives, these new organizations could try to evolve into for-profit corporations. Plus, existing healthcare organizations could try to convert themselves into co-ops. Either way, they will need informaton to defend their moves because of the history of organizations who lost their way and were not really working for the interests of their members, of consumers or the public.
Thanks for reading!