Clinical and care management can be defined as a set of activities that either directly impact the health outcome of the population / individual (such as health risk assessment, case management, and medication adherence programs) or indirectly help healthcare organizations provide quality care at lower cost (such as CAHPS and STAR / HEDIS).

While clinical and care management as a segment has existed for a while now, its importance has increased exponentially post ACA. With the US already being the highest spender in the world on healthcare, ensuring care to reduce readmissions and denials of members is the need of the hour. Also, with ACA shifting the focus from volume-based care to value-based care, the healthcare stakeholders are taking proactive measures to ensure quality care at lower cost for members. This shift is supported by the seepage of consumerism in healthcare, motivating the customers or members to be more involved in their care lifecycle. All this is putting pressure on the payers as well as providers to make investments in clinical and care services and at the same time reduce their costs. With the stakeholders struggling to find the right talent, domain, and technology expertise in house, they are looking for the outsourcing route to help them in their journey.

Such a scenario presents BPS service providers with a host of opportunities; however, third-party vendors need to enhance investments in building capabilities in areas such as consulting / design thinking, technology, and domain-led services to ensure they plug gaps where payers and providers lack in-house capabilities.

The scope and methodology of this report includes:

• Relative positioning of 16 service providers on Everest Group’s PEAK Matrix™ for clinical and care management BPS
• Analysis of service provider’s market share
• Everest Group’s analysis of service providers’ strengths and areas of improvement

Membership(s)

Healthcare & Life Sciences BPO