Andrew CohenThe opening of enrollment for public health insurance exchanges and growth of private health insurance exchanges have the potential to fundamentally alter hospitals' and health systems' patient populations and payer mix.

The exchanges will present both challenges and opportunities related to revenue and market share, and, ultimately, to an organization’s ability to generate excess cash flows to continue its mission. Hospitals and health systems may increase revenue through expansion of coverage to the uninsured, but in many states, more exchange enrollment is projected to originate from individuals with existing commercial coverage. The possibility that exchange reimbursement will be less than today’s traditional commercial reimbursement puts organizations at risk of losing a significant portion of their current commercial revenue. 

Catalyzing a Shift to More Challenging Payment Models

Charles Kim

The health insurance exchanges are marketplaces that allow individuals or businesses to compare a variety of healthcare plan options and purchase coverage. Public exchange plans will be effective Jan. 1, 2014, and target uninsured, underinsured, and self-insured individuals. The Small Business Health Options Program (SHOP) will target small employers.

With private exchanges, employers contract with a private exchange operator, which typically is an insurance company or benefits management/consulting company. Under defined contribution plans, employees then are allotted a fixed dollar amount from their employer to apply toward a health plan of their choice purchased in the exchange.

Both types of exchanges reflect a “retail” (or individual) purchasing environment. As lives move from the “wholesale” (employer group) environment to the “retail” channel, we expect the shift to accelerate the adoption of high-deductible and narrow-network products. Therefore, the movement of commercial lives into exchanges potentially represents reduced reimbursement and market share loss for hospitals and health systems. 

Anticipating Shifts in Patient Population

Jason O'Riordan

Estimates of future enrollment through the exchanges vary. The Congressional Budget Office projects that 25 million people will receive coverage through the public exchanges by 2016.

The degree of commercial shift to public exchanges will differ by segment. Individuals insured through employer-sponsored plans make up the majority of the existing commercial market. Those insured through small employers are most likely to opt into the public exchanges, either because their employers will participate in the SHOP exchanges or discontinue coverage altogether.

A significant portion of the population of patients with individual commercial coverage is expected to shift to public exchanges to access a broader choice of coverage and federal subsidies available to individuals with incomes lower than 400 percent of the Federal Poverty Level. 

Private exchange operators such as Aon Hewitt are targeting large employers, with Walgreens being a recent example of a new private exchange participant. However, other exchange operators (e.g., Liazon) and brokers are designing private exchanges for small employers as well. Therefore, we expect both small and large companies to migrate to private exchanges over time.

A Kaufman Hall analysis estimates that 16 to 66 percent of hospitals’ current commercial lives will be at risk for transfer to the public and private exchanges by 2018. The midpoint scenario projects a 40 percent shift with:  

  • Private exchanges constituting 23 percent
  • Individual public exchanges constituting 13 percent
  • SHOP exchanges constituting 4 percent 

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We expect the degree of shift to vary materially by market, making it critical for hospitals and health systems to comprehensively analyze their commercial populations and employer demographics to develop market-specific projections. 

Preparing for a New Payer Mix

Hospitals and health systems should be proactive but thoughtful in developing their exchange strategies, and should be actively involved in conversations with payers and employers. Conducting a thorough analysis of the potential impacts on your organization’s patient population and payer mix is an essential first step. 


Andrew Cohen is a vice president in the strategy practice at Kaufman, Hall & Associates Inc., Skokie, Ill. Charles Kim is a senior vice president and Jason O’Riordan is an assistant vice president in the firm's financial planning practice. 

Publication Date: Friday, October 18, 2013