The Pressure Health Plan Leaders Face
Health plan leaders have always operated in complexity. However, the current environment stands apart. Regulatory pressure, affordability concerns, a slow shift to value-based care, and the weight of modernizing outdated systems are all converging at once. Furthermore, leaders must make high-stakes decisions with shrinking margins for error and imperfect data.
Becker’s asked 11 payer executives to identify one challenge they are currently navigating. Their responses covered a wide range — from IDR process abuse and VBC investment lag to member trust and redefining healthcare purchasing altogether.
The Value-Based Care Investment Gap
Why Providers Struggle to Invest Upfront
Jennifer Howard, MSN, RN, Lead Director of Value-Based Care Provider Engagement, CVS Health Aetna (Hartford, Conn.), identifies the lag between upfront investment and financial return as one of the most persistent barriers in value-based care. Providers must invest heavily in human capital, care management resources, and data analytics before seeing any financial benefit. The returns often arrive years later. Consequently, many organizations with tight margins hesitate to commit.
How Payers Can Help Bridge the Gap
Howard recommends three approaches to address this challenge. First, payers can offer upside-only or shared savings contracts so providers build workflows gradually before assuming downside risk. Second, providers can leverage payer data — including claims insights, utilization patterns, and predictive modeling — instead of building costly in-house analytics immediately. Third, regular annual reviews of what is working and what is not help keep payer-provider partnerships aligned and sustainable over time.
Modernizing Utilization Management
Uche Olekanma, MD, Vice President of Clinical Operations, Blue Cross Blue Shield of Arizona (Phoenix), points to utilization management modernization as his primary challenge. Currently, payers face rising regulatory pressure, increasing medical costs, and widespread clinician burnout. Therefore, BCBS Arizona is working to move away from transaction-heavy models toward a data-driven, clinically nuanced, and collaborative approach. This includes reducing unnecessary administrative burden, aligning decisions with current clinical evidence, and applying physician-led governance to improve transparency.
IDR Process Abuse and Cost Inflation
James Grana, PhD, Vice President of Value-Based Care Programs, BlueCross BlueShield of South Carolina (Columbia), highlights the growing misuse of the Independent Dispute Resolution process. Specifically, certain providers submit high volumes of questionable filings and use strategic batching that strains system capacity. These practices raise administrative costs and push overall healthcare spending upward — without improving care quality or patient experience. Ultimately, this inflationary behavior raises member premiums rather than improving affordability or access.
Misaligned Employer Benefit Designs
Ruchika Talwar, MD, Medical Director of Population Health and Urologic Oncology, Vanderbilt University Medical Center (Nashville, Tenn.), observes that even as value-based care gains momentum, many employer benefit designs still reward volume over outcomes. This misalignment slows adoption of innovative models such as direct-to-employer bundled programs. Moreover, scaling these programs requires employers to rethink legacy benefit systems not built for outcomes-based approaches. At Vanderbilt Health, teams actively work to bridge this gap by creating offerings that integrate with existing infrastructure while demonstrating measurable impact.
AI Integration and Provider Directory Gaps
Tiffany Kobashigawa, Director of Strategy, Sales and Service, LA Care Health Plan (Los Angeles), identifies AI-driven digital tool integration as her core challenge. Specifically, automating complex enrollment workflows while simultaneously managing provider directory lag at the point of enrollment creates friction for both members and providers. She notes this is an industry-wide issue, not unique to LA Care. As a result, the organization is actively pursuing tech solutions that not only improve efficiency but also strengthen member retention.
Rethinking Insurance as Healthcare Purchasing
Jonathan Baran, Co-founder and CEO, Self Fund Health (Madison, Wis.), argues that most employers still think they are buying insurance when they should be buying healthcare directly. His company demonstrated this with a Wisconsin member sent to Johns Hopkins for open-heart surgery at a bundled cost of $76,000 — versus $219,000 at a local hospital. Traditional insurance rents a PPO network and passes through whatever a hospital charges. In contrast, direct healthcare purchasing gives employers price and quality transparency before any procedure takes place. Shifting that mindset among employers, brokers, and hospitals remains his greatest challenge.
Leading Dispersed Teams with Clarity
Rhonda Mims, Executive Vice President and Chief Public Affairs and Risk Officer, AmeriHealth Caritas (Philadelphia), focuses on the challenge of leading geographically dispersed teams. She emphasizes that high-performing distributed teams do not need to be in the same room — but they do need shared clarity. Her team’s approach rests on five principles: clear priorities and defined roles, intentional connection through regular touchpoints, trust built through managing impact rather than presence, predictable communication cascades, and sustained human connection. In healthcare especially, where the work is mission-driven, keeping people aligned and feeling seen is essential.
Building Member Trust in New Markets
Meredith Duncan, President and CEO, Texicare (Austin, Texas), highlights that entering a new market with a new name does not automatically generate trust. Moreover, for small businesses that have historically had limited healthcare options, action requires more than awareness. Texicare’s strategy centers on consistent community presence and relationship-deepening with Texans — because, as Duncan notes, they deserve a healthcare partner as invested in their communities as they are.
Affordability as a Core Strategy
Jennifer St. Thomas, Senior Vice President of Commercial and Medicare Markets, Mass General Brigham Health Plan (Somerville, Mass.), places affordability at the center of her organization’s strategy. In a difficult economic climate, the goal is to keep products competitive and deliver real value while supporting individual member health needs. This includes thoughtful decisions around benefits design, care coordination, and provider partnerships that promote both sustainability and quality. Staying member-focused means ensuring access to high-quality, affordable care for the communities they serve.
Educating Small Businesses on Self-Funding
Ty Wang, Co-Founder and CEO, Angle Health (San Francisco), points to persistent misconceptions about self- and level-funding among small businesses and their brokers. Today, high-quality alternatives to traditional funding models give small businesses greater cost control and data ownership — while remaining familiar and easy to administer. However, the primary barrier to adoption remains a lack of awareness and education. Closing that knowledge gap is central to expanding access to better funding options for smaller employers.
Navigating the CMS 2027 Medicare Advantage Rule
Martina Lee Strickland, Head of Marketing, PR and Brand, Clever Care Health Plan (Huntington Beach, Calif.), describes the CMS 2027 Medicare Advantage and Part D Final Rule as one of the most comprehensive in recent memory. Additionally, geographic variation means the regulatory picture looks different county by county across Southern California. Clever Care is actively working to understand what these changes mean for its members. Nevertheless, the core mission remains constant: stay close to members, ensure access to providers, improve health outcomes, and deliver an excellent care experience.
Sustaining Value-Based Outcomes at Scale
Chris O’Donnell, Vice President of Provider Network Innovation and Strategy, Lifetime Healthcare Cos. (Rochester, N.Y.), shares that approximately 70% of Lifetime’s membership is currently in value-based care arrangements. While these arrangements have driven improved clinical and quality outcomes, sustaining affordability alongside quality performance remains an ongoing challenge. Therefore, the organization continues to innovate and refine incentive alignment strategies that can maintain clinical excellence while reducing overall healthcare costs for members.
