Healthcare Plans
This sector consists of managed care companies and health insurers that administer medical benefits and negotiate provider networks to cover the cost of care for members.
Why it exists
Healthcare plans exist to pool medical risk and manage cost of care.
Why it’s necessary
Without risk pooling, healthcare becomes financially catastrophic for individuals.
Key components
Member enrollment systems
Provider networks
Claims processing
Risk adjustment and actuarial modeling
How to evaluate businesses
Medical loss ratios, member growth, government vs commercial mix, retention, and administrative efficiency are core metrics.
How the industry could be improved
Outcome-driven reimbursements, real-time utilization tracking, preventative care incentives, and AI-driven fraud detection.