Payers, growth challenges may be hiding in your sales model

Blog series: How healthcare payer sales models impact revenue growth

By Alex Tolmasoff, Director, KPMG Sales Transformation and HCLS Lead

In our three-part healthcare payer sales model series, we discuss the hurdles sales leaders face with finding and keeping members, how outdated sales models can impact revenue growth, and how updates to your sales model can impact results.

Prior to COVID-19, health insurance carriers faced a challenging market with new entrants, new products, and high patient and provider expectations. First, COVID-19 increased the pressure to maintain revenue growth and margins, while delivering new services that engage members virtually and digitally. At the same time, legacy sales model issues did not get easier – if anything they got more complex and challenging. Commercial leaders today need to re-examine their sales models to ensure they keep up with member expectations and gain access to new members.

What’s so difficult? A member is a member, right?

Wrong. Not all members are created equal, and not all have the same desire or ability to consume high growth or high margin offerings. Without good customer intelligence and aligned sales enablement, such as analytics, revamped sales processes, new training and coaching, and updated incentives, leaders are likely to see:

  • Poor expansion of ancillaries, such as dental and wellness, with high growth and margin potential
  • Focus on accounts that want lower margin narrow networks and self-funded business
  • Increased Selling, General, and Administrative (SG&A) costs and decreased productivity per seller  

The five “big rocks” to climb for better member access

1. With more government spending, sales models need to adapt their strategy and composition

  • CARES Act, the Inflation Reduction Act, and PPA stimulus in 2020-2021, though temporary, boosted patients’ ability to consume care and accelerated ACA adoption, resulting in the largest enrollment ever in 2021 and 2022 1,2
  • Implication: Many sales models are not well-adapted to high volume, digitally driven motions are required to access and serve this market

2. Increasing payer and healthcare service consolidation puts pressure on sales leaders to act more nimbly and strategically

  • Many organizations are increasing economies of scope rather than scale (e.g., buying up complementary services, ancillary offerings, and sites of care) to diversify their portfolio, capture more of the value chain, and improve data capture on outcomes
  • As a result, traditional large health insurance carriers now generate significant revenue and margin based on non-insurance products and services
  • Implication: Smaller payers will face increasing competition, from vertical integration and well-funded competitors, and need to relook at where and how they will win

3. Rising acceptance of telehealth by providers and patients requires new digital sales motions and new expertise

  • COVID-19 accelerated the use of virtual technology by patients and providers, making them more comfortable with these technologies, and employers are increasingly offering this as a standard benefit
  • Centers for Medicare & Medicaid Services (CMS) changes in 2020 and 2021 opened doors for comprehensive telehealth coverage and virtual clinic models, making these platforms and approaches financially feasible for providers and payers
  • In 2022, < 25% of clinicians said they will go back to "business as usual," and anticipate making telehealth a normal part of patient service3
  • Implication: Increased comfort by providers, employers, and members with telehealth means that sellers can expect to both offer new tech-focused products as well as change how they sell to accommodate new buyer preferences

4. Rise of behavioral health intervention apps (both home grown and stand-alone) require new business models and sales models to be successful

  • Wellness and behavior-change applications and their supporting service offerings are high margin and have high potential for growth
  • Several large national health insurance carriers have created "home grown" behavioral health solutions with varying success as they compete with these digital-native and well-funded health tech companies
  • Implication: Selling these products requires a new B2B2C model that requires sellers to sell differently, to work with new business partners, and to work closely with patient success teams that drive adoption (which operate with a much higher touch than standard health insurance patient care teams)

5. New market entrants with deep pockets will challenge legacy sales models

  • Relaxed Blue monopoly regulation is allowing large and new carriers to play in previously protected markets
  • Well-resourced and focused health insurance offerings and partnerships are continuing to grow from non-traditional tech and retail players such as Amazon and Walmart, which are focused on growth
  • Implication: Sales leaders need to both assess their markets and segments for competitive threats, while working with product, finance, and actuary to prepare for creative pricing and contracting


As a result of these challenges, payers must contend these issues:

Direct to consumer and broker-led selling is sub-optimized as they fall outside commercial employer models

Small payers will need to be more nimble to counteract larger portfolios. Large payers will need to coordinate across disparate offerings and teams

Traditional selling teams will need to adapt how they bring offerings to market or risk getting flanked by more nimble digital-native competitors

Value props for internally created offerings will need to be well-articulated, inexpensive and demonstrate results. If they are not, payers will want to quickly find partners and platforms to co-selling

New market entrants will have to compete for sales talent with high salaries

They must carve out customer niches that were once well protected

As a result of these “big rocks”, sales leaders must gain ground—and member access. Healthcare payers must shift to a new way of thinking and adopt a holistic sales approach.

See the next blog in our series on the issues that payer sales leaders will face if they continue to rely on traditional sales models.

How can KPMG help?

As you focus on the challenges ahead, KPMG can help you improve the ROI on your sales investments by informing sales strategies, processes, and talent with connected insights.  We’ll help you create winning customer interactions.


  1. Source: HMS 2021
  2. Source: CMS 2023
  3. Source: KPMG Provider Research Study (2022)

Contact us

Walt Becker

Walt Becker

Principal, Customer Advisory, Sales Transformation, KPMG US

+1 267-256-7000
Alex Tolmasoff

Alex Tolmasoff

Director Advisory, C&O Commercial, KPMG US

+1 415-963-5100