Pharmacy Benefit Managers (PBMs) play a key role in the healthcare industry, managing pharmacy products and facilitating real-time interactions among stakeholders. In recent years, PBMs have expanded beyond their core functions to adapt to evolving market dynamics. Key trends include regulatory changes, increased consumer focus on health management, and widespread technology adoption. In this report, we explore key themes in the PBM marketplace, highlighting common use cases, benefits, challenges, and emerging technologies and opportunities. The report aims to help providers understand the intricacies of pharmacy benefit management and guide enterprises in formulating the right PBM strategies. Scope Industry: healthcare Geography: global Contents In this report, we examine: The role of PBMs and value chain functions Key trends and demand drivers Challenges in adopting technology and associated trends Use cases that leverage AI and automation Investment priorities Membership(s) Healthcare Payer and Provider Information Technology Sourcing and Vendor Management

In the dynamic healthcare landscape, efficient claims management is vital. Traditionally, the claims management process relies on manual efforts and human judgment. Today, advanced analytics allow healthcare payers to optimize costs, reduce fraudulent claims, ensure regulatory compliance, and lower claims denial rates. Implementing analytics strategically in the healthcare ecosystem has significantly enhanced the claims management life cycle. In this report, we examine the role of analytics in transforming claims management, emphasizing the importance for healthcare payers and providers to prioritize analytics in claims management processes. The report assesses key trends, technologies, and focus areas in claims analytics, offering a comprehensive overview of how these advances lead to more efficient and effective systems. Additionally, it addresses the challenges providers face in adopting and implementing analytical techniques while offering insights into overcoming them. The report also examines the current state of claims management, offering actionable recommendations to use analytics to streamline operations and improve outcomes. It will help stakeholders understand the transformative potential of analytics in healthcare claims management and develop strategies to harness its benefits. Scope Industry: healthcare Geography: global Contents In this report, we: Examine the role of analytics in transforming claims management, highlighting how it can optimize costs, reduce fraudulent claims, ensure regulatory compliance, and lower claims denial rates Identify challenges healthcare payers face in adopting analytics and offer insights to overcome them Assess the current claims management status in the healthcare landscape Recommend best practices for using analytics to enhance efficiency and effectiveness Membership(s) Healthcare Payer and Provider Information Technology Sourcing and Vendor Management

In the healthcare sector, effective member engagement is vital for care coordination and improving outcomes. Despite significant investments in digital tools such as telehealth, healthcare payers struggle with adoption due to discrepancies between member needs and available functionalities. Barriers such as demographic differences and limited technology awareness hinder widespread adoption. However, there has been a notable increase in digital channel usage post-COVID-19, although interactions remain largely transactional. Member engagement technology enables data analysis, communication, and self-service but requires improvement to foster more proactive engagement. Members increasingly seek transparency, cost estimates, and wellness information from health plans, with growing interest in wellness management apps. . In this research, we assess start-ups that offer member engagement solutions, focusing on their capabilities and market impact, based on Everest Group’s analysis of exponential technology companies. The report provides insights into the evolving landscape and opportunities for health plans to enhance member engagement and healthcare delivery.. Membership(s) Healthcare Payer and Provider Information Technology Sourcing and Vendor Management

Home-based healthcare is gaining relevance within the healthcare industry. With evolving customer expectations, improved technological stack, and enhanced focus on patient and member experience, home-based healthcare is emerging as a dominant sector. Providers too, are looking forward to delivering care remotely, as it enables them to deliver quality at a reduced cost, which enhances their operating margins as well. A critical aspect of home-based healthcare is patient data. With remote patient monitoring, the sources for capturing volumes of patient data have increased. This has a flip side too, as the challenge of consolidating patient data, processing it, and ensuring data security and privacy has resulted in increased complexity in the application of home-based healthcare. Adoption trends for home-based healthcare have been quite dynamic across the patient spectrum. While primary care has received a boost as it has seen major growth within home-based healthcare adoption, wellness and lifestyle tracking adoption is still in nascent stages. Streamlining home-based healthcare delivery is another important aspect wherein the major healthcare enterprises have looked forward to forging strategic partnerships with technology and service providers to enhance care delivery to patients. Technology has played a critical role in the growth of home-based healthcare with the key focus being on data management, data analytics, and business intelligence. For providers, there are four critical areas of focus, which are care coordination, patient administration, care delivery, and essential management. This Market report provides comprehensive coverage of the current trends within the home-based healthcare market and highlights how technology is becoming an enabler for the home-based healthcare market. The market report will enable providers to keep track of the technological opportunities within the home-based health market, thus staying aligned with the home-based healthcare industry. Scope Industry: healthcare Geography: global Services: home-based healthcare Contents In this report, we: Assess the growing home-based healthcare market, covering the major market drivers, inhibitors, opportunities for service providers, and the ecosystem for home-based healthcare Provide current market analysis of the home-based healthcare market, strategic partnerships within the ecosystem, and major adoption trends across of home-based healthcare across the care spectrum Membership(s) Healthcare Payer and Provider Information Technology Sourcing and Vendor Management

COVID-19 significantly impacted care management technology adoption for healthcare payers and providers. They recognized the importance of leveraging technology to ensure continuous care while reducing transmission risk. The pandemic highlighted the value of data analytics and population health management for understanding disease trends and identifying high-risk populations. By leveraging data-driven approaches, healthcare payers and providers can allocate resources, personalize treatment plans, and address the needs of vulnerable patient groups, thereby improving patient outcomes and healthcare system resilience. Care management technology enables data collection, analysis, and visualization, empowering effective response and resource allocation during COVID-19. Technology solutions are vital for seamless collaboration among stakeholders in care coordination and communication. Patient-centered care models have also gained traction with technology enabling patient engagement and access to resources. Overall, the pandemic accelerated the adoption of care management technology, transforming healthcare delivery and emphasizing the importance of leveraging technology to meet the evolving needs of patients, providers, and payers. In this report, we assess start-ups that offer dedicated care management services, software, and solutions, focusing on their core capabilities and market impact. Scope Industry: healthcare Geography: global Contents In this report, we: Discuss payers and providers’ care management adoption levels Examine the drivers in the care management market Introduce a framework to evaluate high-potential start-ups in the care management market Highlight the trailblazers in care management, including their assessment, leaderboard, and profiles Membership(s) Healthcare Payer and Provider Information Technology Sourcing and Vendor Management

The pandemic initiated a financial downturn for healthcare providers, who were already grappling with administrative inefficiencies, as elective surgeries were halted, and foot traffic decreased. Although patient volumes are gradually returning to pre-pandemic levels, the unprecedented talent shortage exacerbated by the pandemic is posing severe challenges for healthcare providers. As a result, healthcare providers are reconsidering their Revenue Cycle Management (RCM) strategy to future-proof their operations against unexpected disruptions. As part of this strategic overhaul, healthcare providers are becoming more open to outsourcing and even offshoring certain operations to third-party providers. The objective is to alleviate cost pressures and ensure the continuity and consistency of operations. Healthcare providers are also seeking to transform their revenue cycle function by adopting technology to reduce their reliance on talent and streamline operations. Recognizing this opportunity, multiple RCM start-ups with a focus on transforming RCM functions have emerged over the past decade. These start-ups are constantly innovating to provide agile, scalable, and easily integrable out-of-the-box solutions that deliver deep insights and prescriptive suggestions. In this report, we assess start-ups that offer dedicated services, software, and solutions mainly focused on the RCM market, and evaluate their core capabilities and market impact. Scope Industry: healthcare Geography: global Contents In this report, we: Explore the drivers leading to outsourcing in the RCM market Discuss upcoming themes in the RCM industry Provide an outlook on technology enablers in the RCM market Introduce a framework to evaluate high-potential start-ups in the RCM market Highlight the trailblazers in RCM, including their assessment, leaderboard, and profiles Membership (s) Healthcare Payer and Provider Business Process Healthcare Payer and Provider Information Technology Sourcing and Vendor Management

For a very long time, the healthcare industry has overlooked the experience of its consumers, who are now demanding an experience similar to industries such as retail or banking. Realizing this growing need, consumer experience has become an executive-level priority in the last couple of years, with most healthcare leaders agreeing that they are in the business of selling an experience and not a product. To address this need, healthcare payers are investing in consumer experience technologies that can help them acquire and retain consumers by making an impact on every aspect of the consumer journey. Improved member experience is a win-win solution for members as well as payers, as it can improve payer finances, reduce administrative costs, and enhance the quality of care. In this research, we deep dive into the rise of customer experience solutions, analyze the different kinds of offerings, and compare platforms available in the market based on their ability to meet payer needs. Scope Industry: healthcare Geography: global Contents: In this research, we focus on: The focus on member experience Evolution of member experience solutions Key vendor landscape Membership (s) Healthcare Payer and Provider Information Technology Sourcing and Vendor Management

The healthcare industry has experienced an exponential rise in data, following the adoption of smartphones, wearables, and electronic health records, which can revolutionize the healthcare industry. Healthcare organizations are monetizing this data to generate revenue, reduce costs, and improve clinical care outcomes. They can either directly sell this data or use it to draw insights to enhance their internal operations. The larger ecosystem, in turn, benefits by the enhanced clinical results derived from this data. In fact, several startups are using data to test their new innovations and deliver better therapies and care. In this report, we study four key data monetization models in use presently – bilateral data exchange, open platforms for data exchange, open marketplaces for data exchange, and open marketplaces for patients to sell data. We also analyze current adoption and the scope of scaling these models. We believe that while the benefits of monetizing data are many, the privacy and security challenges accompanying it cannot be ignored and need to be addressed at the earliest. Scope Geography: global Industry: healthcare Sources leveraged: expert analyst inputs, Everest Group research, publicly available secondary data sources Contents In this research, we: Define data monetization in healthcare Study four key models of data monetization in healthcare Understand the privacy and security challenges accompanying healthcare data monetization Membership(s) Healthcare IT Services (ITS) Data & Analytics