12 Opportunities Payers: Introduction
In the rapidly evolving healthcare landscape, payers have a unique opportunity to drive significant improvements in healthcare equity, patient outcomes, and operational efficiency over the next year. The focus for 2025 is on aligning cost-efficiency with high-quality care, embracing technology, and pushing the boundaries of value-based care.
1. Balancing Cost and Quality of Care
Damanjeet Chaubey, MD, Vice President of Clinical Affairs, Clover Health
One of the biggest challenges and opportunities payers face is balancing the cost of care with quality outcomes. With the aging population and expensive medical innovations, payers must focus on creating synergies across their organizations to provide timely interventions and value-based care. Aligning priorities within the organization is critical to delivering better care outcomes while managing escalating healthcare costs.
2. Personalization in Healthcare
Akrom Hossain, Senior Director of Healthcare Management, BCBS Illinois, Montana, New Mexico, Oklahoma & Texas
Personalization is becoming a game-changer in healthcare. Payers have the chance to make healthcare more accessible by integrating point solutions and using technology to offer personalized care experiences. The key lies in meeting members where they are, offering resources through preferred channels, and supporting providers in delivering holistic care that addresses whole health and wellness.
3. Leveraging AI for Efficiency and Growth
Michael Hunn, CEO, CalOptima Health
Artificial intelligence (AI) can transform network adequacy by improving primary care provider efficiency, addressing physician shortages, and streamlining administrative tasks like claims payments and same-day authorizations. By adopting dynamic AI technologies, payers can enhance their operational capabilities, providing more timely and accurate care while controlling costs.
4. Providing Care Management Support
Michael Kobernick, MD, Senior Medical Director, Health Plan Business, BCBS of Michigan
Supporting members during difficult care journeys through robust care management programs is another vital opportunity. Payers need to offer tailored support, especially to members managing chronic conditions, by providing personalized resources and coordinating care to enhance their healthcare experiences and outcomes.
5. Ensuring Stability Amidst Change
Hilary Marden-Resnik, President and CEO, UCare
With significant regulatory changes looming, such as updates to Medicare Part D and the potential expiration of tax credits in the individual market, payers must act as stabilizing forces in the healthcare ecosystem. They need to support their members through these transitions, advocate for policies that maintain marketplace affordability, and re-enroll individuals who lost Medicaid coverage during redetermination processes.
6. Adopting AI for Operational and Clinical Success
Ria Paul, MD, Chief Medical Officer, Santa Clara Family Health Plan
AI’s role in healthcare is expanding, and payers must adopt this technology in both operational and clinical areas. By using AI for claims processing, revenue cycle management, and risk stratification, payers can improve efficiency and accuracy. Care coordination will also benefit from AI, allowing payers to track members across the care continuum and reduce acute care admissions by promoting preventive care.
7. Focusing on Whole Health and Value-Based Care
Chandni Sud-Thavakumar, EdD, Vice President, Performance Operations, Mass Advantage
Payers should shift their focus toward whole health, emphasizing value-based care models that prioritize specialty care. Building stronger collaborations between payers, networks, and members will be essential to improving health outcomes, retaining members, and delivering better healthcare experiences.
8. Integrating Virtual Behavioral Health Services
Philip Randall, Director, Population Health and Community Programs, Banner|Aetna
Virtual behavioral health services present a significant opportunity for payers to improve member outcomes. By making these services more accessible and affordable, payers can help members manage chronic conditions and enhance their health literacy. A well-researched and integrated strategy will be crucial in getting these services to those who need them most.
9. Improving Health Equity Initiatives
Ilan Shapiro, MD, Chief Health Correspondent and Medical Affairs Officer, AltaMed Health Services
Healthcare plans must engage communities to improve health outcomes. The next 12 months present an opportunity for payers to integrate health equity initiatives into their care models, ensuring that all populations receive appropriate care and resources tailored to their unique needs.
10. Utilizing AI in Value-Based Payment Models
Anthony Thompson, Senior Vice President, Healthcare Network Strategy, CDPHP
Machine learning and generative AI are reshaping how payers design value-based contracts. These technologies allow payers to streamline payment models by analyzing patient data and predicting health risks, which helps prioritize preventive care and improve outcomes in value-based care environments.
11. Addressing Health Disparities and Equity
Johanna Vidal-Phelan, MD, Chief Medical Officer, UPMC Health Plan
Advancing health equity should be a top priority for payers in the coming year. By incorporating equity goals into value-based care programs and collaborating with community organizations, payers can reduce health disparities and improve care for underserved populations. This focus on health equity will foster trust and lead to better resource allocation and care delivery.
12. Collaborating for Value-Based Care Models
David Wang, MD, Chief Operating Officer, Mass Advantage
With margin pressures increasing, payers must collaborate with providers to build sustainable value-based care models. Payers can better contain healthcare costs and ensure long-term success in delivering high-quality, affordable care by focusing on contracting and care transformation.
FAQs
1. What is the biggest challenge for payers in the next year?
A. The biggest challenge for payers is balancing cost efficiency with delivering high-quality care while adapting to new regulations and technologies.
2. How can payers improve health equity?
Payers can improve health equity by integrating equity goals into value-based care programs and collaborating with community organizations to address healthcare disparities.
3. Why is AI important for payers?
AI improves efficiency, accuracy, and personalization in healthcare, helping payers streamline operations, enhance care management, and design better payment models.
Conclusion
The next year offers a range of opportunities for payers to reshape the healthcare landscape through innovation, technology, and a renewed focus on value-based care. From balancing costs while maintaining quality to leveraging AI for operational efficiency and health equity, payers are well-positioned to make a significant impact on patient outcomes and overall healthcare delivery. By adopting personalized care models, enhancing virtual health services, and building stronger collaborations with providers, payers can create sustainable systems that address the growing needs of diverse populations. These initiatives, when executed effectively, will ensure not only improved healthcare experiences for members but also long-term stability and growth within the healthcare ecosystem.
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