Positioning for continued growth in public exchanges

Most payers competing in federally facilitated marketplaces or state-based exchanges are past the initial stages of implementation. Now is the time for payers to think about taking their plans to a new level, with greater consumer-oriented offerings and engagement approaches — supported by efficient operations, sophisticated data analytics and risk modeling.

What are some areas of concern when it comes to planning for 2016 and 2017?


Geographic breakdown









  • Small group expansion. As of 2016, the small group definition is going to expand up to 100, and there are numerous risks associated with this change. Some of these “larger-smaller” groups may decide to self-insure. New reinsurance that’s available to reinsure such groups may be an incentive for small groups to leave the market, and leave the less healthy in the market, which will increase premiums for everyone.
  • Renewed focus on consumer retention. What steps are you taking to ensure that you retain your membership, whether through active outreach campaigns or leveraging direct enrollment? How are you keeping consumers more guided toward your plan and policies offered on the exchanges?
  • Policy-level premium payment impacts. The policy-level premium payment will become critical as we move away from what’s been in place the past 12 months around group payments. Payers are now starting to understand there is a financial impact to this — using more sophisticated ways to analyze back-end data to ensure accuracy and to focus on compliance-related activities in the future.
  • Marketing for success. State-based exchanges have a limited ability to market — basically it comes down to brand and price. We are now seeing retention, not acquisition, where it pertains to marketing. Over the last few years, the marketing of health plans has gone from a membership model to a consumerism model. How can we become more like the big-name retailers of the world when it comes to marketing on a health care exchange? Do you have the internal tools and capabilities to execute a successful strategy?

For further discussion of considerations in regard to the future of public exchanges, download our article “Positioning for continued growth in public exchanges.”


About the authors

Jeffrey K. Lowry, BS, MHA
Vice President, Payer Exchange Consulting, Optum

JeffLowry_100Jeff brings 30 years of experience from both the provider and payer sides to his role at Optum, most recently setting up an Exchange Health Plan (individual products) on the State of NY Marketplace.  Jeff leads Optum’s strategy development and consulting delivery implementation work across both public and private exchanges.

Craig Howarth
Senior Director, Payer Consulting, Optum

Craig HowarthCraig brings 15 of years of experience in the healthcare industry, focused on process improvement and customer experience enhancement.  He specializes in large scale transformations around operational improvements, data management, segmentation, and campaign management.  Most recently, Craig led Optum’s consulting work on both the MA and VT health exchange solutions.

Kecia Rockoff, FSA, MAAA
Actuarial Director, Payer Consulting, Optum

kecia_rockoffKecia brings 25 years of experience in the financial aspects of health care management.  She specializes in developing predictive solutions to measure the actuarial and financial impact of market changes such as ACA’s 3Rs and ICD-10, for example.  Most recently she has participated in a variety of consulting roles on the MA, FFM and VT health exchange solutions.

Michael Nestor
Vice President, Payer Consulting, Optum

MikeNestor_picMichael Nestor is a Vice President in the Optum Payer Consulting group. A successful executive with almost 20 years’ experience, Mike has led complex enterprise business and technology initiatives to deliver innovative new products and technology solutions that enhance customer satisfaction, drive revenue growth, and reduce operational expenses.

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