Selling to health plans

Health plans buy outside help when medical costs climb faster than premiums. That gap is the pressure that shapes almost every decision they make.

Payers are a different world from health systems. They run like insurers, think in terms of risk and ratios, and sit on mountains of data. They buy a lot of outside help. But they're hard to sell to if you don't understand how a plan makes and loses money.

Who buys

At a health plan, the big services decisions usually run through a few seats. The CIO owns core administration systems, claims platforms and infrastructure. The CFO owns cost, reserves and the medical cost ratio. The chief operating officer owns claims, enrollment, member services and provider relations.

There's often a chief medical officer or a head of care management with a say on anything touching clinical programs. And there's a chief data or analytics officer at larger plans, sometimes with their own budget.

Your champion is usually a VP or director who runs a function under one of those leaders. Claims operations, payment integrity, member experience, or a specific line of business like Medicare Advantage or Medicaid.

The pressures they face

Medical cost is the big one. When utilization rises, margins shrink fast. Plans look hard for ways to manage cost without hurting members or providers.

Regulatory change never stops. New rules on interoperability, prior authorization, price transparency and quality ratings all need systems work, often on a deadline.

Legacy platforms are common. Many plans still run claims on old core systems. Modernizing them is expensive and risky, but staying on them is getting harder.

And member experience matters more each year. Star ratings in Medicare and renewal rates in commercial plans depend on how members feel about their plan.

The signals that matter most here

Business pressure is the strongest signal. Public health plans report medical cost trends every quarter, and leaders talk openly about utilization and margin. A plan that flags rising cost in an earnings release is under real pressure to act.

A new leader is next. A new CIO, COO or head of a line of business comes in with a mandate. In their first 90 days, they're looking at vendors, platforms and the team.

Regulatory deadlines act like a signal of their own. When a new rule takes effect, every plan has to comply. That's a predictable wave of work for firms that know the domain.

Hiring for the problem matters a lot. Plans posting for months for claims systems engineers, data engineers or interoperability specialists are telling you where they're stuck.

An example opener

Say a regional health plan announced a new COO, and its last quarterly report flagged higher than expected utilization in its Medicare Advantage business.

Saw the last report flagged higher utilization in Medicare Advantage, right as you've stepped into the COO role. My guess is you're finding that the prior auth and care management workflows aren't giving you a clear enough view to act on it quickly. Is that close, or is the real gap somewhere else?

It's specific to the plan. It's tied to the new seat. It guesses at a real operational problem. And it invites correction.

What to avoid

Don't sell like you're selling to a hospital. Health plans aren't care providers. If you mix up their language, they'll notice in the first line.

Don't promise savings you can't back up. Plans are full of actuaries and analysts. Loose claims about cost reduction will get picked apart.

And don't skip the compliance angle. Anything touching member data, claims or clinical decisions has strict rules. Show early that your firm knows them.

Where to start

Pick a set of plans in your region or a line of business you know well. Read their filings, or their annual statements if they're nonprofit. Watch for leadership changes, rising cost trends and regulatory deadlines.

When those signals stack up at one plan in the same few weeks, reach out to the full committee. This piece on selling to health systems covers the provider side, and the two often work together on the same problems from opposite ends.