The US spends about $5 trillion a year on healthcare, roughly 18% of GDP (CMS National Health Expenditure accounts; verify latest year). Almost none of that money passes directly from the person who receives care to the person who gives it. An insurer, an employer, a government program or a pharmacy benefit manager usually sits in between, and each one has its own revenue unit, its own budget cycle and its own idea of value. A healthcare business model is first an answer to three questions: who pays, per what unit, and out of whose budget? This section maps the revenue units used across healthcare (fee-for-service, case rates, capitation, percent of premium, PEPM, per-enrolled-member fees, subscriptions, software licences, transaction fees, rebates), the unit economics that follow (per-member math, provider margins, two-layer CAC and payback in B2B2C, gross margin by model, capital intensity and working capital), public benchmarks, cases and pitfalls. A worked example computes the economics of a digital chronic-care program sold to employers, and a checklist sets out diligence questions by business type.
What the study covers
- 1Overview: why healthcare business models are unusual
- 2The revenue units
- 3Mechanics
- 4Margins by model
- 5Key numbers and public benchmarks
- 6Landmark cases
- 7Pitfalls
- 8How an expert thinks about it
- 9Glossary
Technical exhibits
Worked examples, checklists and case studies included with this study.
B2b2c Digital Health Payback Worked Example
A stylized digital chronic-care program sold to a self-insured employer: eligible-to-enrolled funnel, per-enrollee vs PEPM pricing, fees at risk, channel fees, two-layer CAC, client payback and the employer's ROI (computed in Python)
Healthcare Business Model Diligence Checklist
Questions to ask of any healthcare revenue model, by business type