14 Payer Tips for Thriving in Healthcare Today: Introduction
The healthcare industry is constantly evolving, driven by numerous external and internal pressures that are reshaping the payer landscape. Executives from across the sector are monitoring regulatory changes, rising healthcare costs, and ongoing provider shortages. These headwinds are forcing payers to adapt their strategies to ensure quality care, affordability, and accessibility for millions of Americans. In this article, we explore the insights of 14 prominent payer executives as they navigate these challenges.
Regulatory Changes
Jack Hooper (CEO and Co-Founder, Take Command Health)
Jack Hooper identifies the biggest headwind as the resistance to change in the group health insurance market. Hooper emphasizes that while the market isn’t functioning optimally, stakeholders are clinging to outdated models. He sees the adoption of Individual Coverage Health Reimbursement Arrangements (ICHRA) as the key to creating a sustainable marketplace, despite the significant shifts required from both clients and industry stakeholders.
Aric Sharp (Divisional CEO, Value-Based Care, Clover Health)
Aric Sharp highlights several regulatory challenges in the Medicare Advantage sector. Increased utilization, financial pressures from the Inflation Reduction Act, and new regulations like V28 are forcing payers to rethink their strategies. These headwinds are driving many to withdraw from specific markets or redesign their benefit plans for 2025. However, Sharp believes that this creates opportunities for innovative payers who can adapt to these changes.
Jennifer Shermo (Chief Growth Officer, Security Health Plan of Wisconsin)
Jennifer Shermo views regulatory uncertainty as a key challenge. As programs like Medicare, Medicaid, and the ACA evolve, Shermo stresses the need for cost containment while ensuring high-quality care and member satisfaction. Rising healthcare costs, inflation, and the complexities of regulatory changes are compounding these challenges, making it more difficult for payers to maintain a balance between affordability and quality.
Alessa Quane (Chief Insurance Officer, Oscar Health)
Alessa Quane focuses on the importance of enhanced tax credits, particularly for low-income ACA enrollees. These credits have allowed over 19 million individuals with incomes below 400% of the Federal Poverty Level to afford health insurance. If the tax credits were to expire, millions of ACA enrollees would face difficult financial choices, potentially leading to inadequate coverage and higher long-term costs. Quane advocates for a bipartisan solution to ensure ongoing access to affordable healthcare for vulnerable populations.
Krischa Winright (President of Medicare Advantage, Blue Cross Blue Shield of Michigan)
Krischa Winright emphasizes the challenges facing Medicare Advantage plans due to rising healthcare costs, increased utilization, and growing senior populations. By 2030, nearly a quarter of Americans will be 65 or older, which will significantly impact Medicare Advantage plans. Winright believes that successful plans will be those that embrace innovation, accelerate performance, and build strong partnerships with healthcare providers to improve care quality for seniors.
Affordability and Cost Pressures
Joe Glinka (Director of HealthChoices, Highmark Wholecare)
Joe Glinka is focused on the financial impact of the Public Health Emergency’s continuous enrollment unwinding, which has led to a higher acuity among remaining Medicaid enrollees. As healthier individuals exit Medicaid, the population that remains tends to have more complex and expensive healthcare needs. Additionally, the surge in utilization of GLP-1 medications for diabetes and obesity has compounded these challenges. Glinka calls for regulatory reviews to ensure Medicaid Managed Care Organizations (MCOs) remain financially viable through actuarial soundness and appropriate rate adjustments.
Tom Grote (CEO, Banner | Aetna)
Tom Grote highlights the rising costs of advanced treatments, such as GLP-1 medications and genetic therapies, as a significant headwind. While these treatments offer tremendous benefits, their cost is a major concern for payers. Grote believes that the shift to value-based care models, which emphasize outcome optimization, will be crucial in balancing cutting-edge treatments with affordability.
Jeremy Wigginton (Chief Medical Officer, Capital Blue Cross)
Jeremy Wigginton points to healthcare affordability as the most pressing issue, driven by rising labor costs, increased utilization of expensive treatments like GLP-1s, and a growing need for behavioral health services. To address these challenges, Wigginton stresses the importance of educating members about cost-effective care options, expanding value-based care models, and working closely with providers to ensure members receive high-quality services at affordable prices.
Access and Provider Shortages
Sonny Goyal (Senior Vice President, Diversified Business Group, Blue Cross NC)
Sonny Goyal draws attention to the ongoing mental health crisis exacerbated by the COVID-19 pandemic. The shortage of mental health providers, compounded by inflation and the economic fallout of the pandemic, has created barriers to care. Goyal advocates for integrating behavioral health into value-based care models to ensure that patients receive comprehensive, holistic care.
Dennis Hillen (Senior Vice President of Market Leadership, Oscar Health)
Dennis Hillen identifies provider burnout as a major challenge in healthcare. Increasing workloads, administrative burdens, and emotional stress have led to high turnover rates and declining quality of care. Hillen believes that technology can help mitigate these pressures by simplifying administrative tasks and allowing providers to focus more on patient care, ultimately improving both provider satisfaction and patient outcomes.
Edward Juhn (Chief Quality Officer, Inland Empire Health Plan)
Edward Juhn highlights the provider shortages in underserved regions, such as the Inland Empire in California, where provider-to-member ratios are among the lowest in the state. To address this, IEHP has created innovative partnerships with local medical schools, offering full scholarships to future providers who commit to serving the community. Juhn also emphasizes the importance of addressing social determinants of health through community health workers who assist members in managing chronic conditions and accessing preventive care.
Jim Laughman (President, Intellectual and Developmental Disabilities Solutions, AmeriHealth Caritas)
Jim Laughman stresses the shortage of behavioral health clinicians, particularly in rural areas. Laughman advocates for telehealth as a potential solution, enabling patients to access behavioral health services regardless of their location. However, he calls for uniform telehealth regulations across states to ensure consistent access to care and streamline reimbursement processes for providers.
Social Determinants of Health and Medicaid
Ray Prushnok (Executive Director, UPMC Center for Social Impact, UPMC Health Plan)
Ray Prushnok sees Medicaid rate adequacy as one of the biggest threats to health equity. UPMC Health Plan has made significant strides in addressing social determinants of health by partnering with public benefits programs and community-based organizations. Programs such as SNAP and housing support have shown promise in improving health outcomes while reducing costs. However, Prushnok cautions that without adequate Medicaid funding, these efforts may be difficult to scale and sustain.
Shelley Turk (Divisional Senior Vice President of Illinois Health Care Delivery, Health Care Service Corp.)
Shelley Turk emphasizes the need for strategic foresight in navigating economic and provider headwinds. Inflation, unemployment, and rising labor and material costs often translate into increased rate requests from providers. Turk advocates for proactive decision-making around value-based care and negotiated rates to maintain access to care for both underserved communities and commercial populations. She believes that anticipating economic changes is key to maintaining stability in the healthcare system.
Conclusion
The healthcare industry is at a critical juncture, with payer executives navigating complex headwinds such as regulatory changes, rising costs, and provider shortages. These challenges require innovative solutions and a commitment to ensuring affordable, accessible, and high-quality care for all. By focusing on value-based care models, leveraging technology, and addressing social determinants of health, payers can mitigate these headwinds and continue to drive positive outcomes for their members.
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FAQs
Q: What are the biggest challenges facing payers today?
A: The biggest challenges include regulatory changes, rising healthcare costs, provider shortages, and increasing demand for expensive treatments.
Q: How are payers addressing rising healthcare costs?
A: Payers are focusing on value-based care models, educating members on cost-effective care options, and collaborating with providers to optimize outcomes.
Q: How can telehealth help alleviate provider shortages?
A: Telehealth can improve access to care, especially in rural areas, by allowing patients to connect with providers remotely, regardless of location.
Q: What role does technology play in reducing provider burnout?
A: Technology can streamline administrative tasks, such as payment processing and medical record management, allowing providers to focus more on patient care.
Q: What impact does Medicaid enrollment unwinding have on health plans?
A: The unwinding of continuous Medicaid enrollment is leading to increased acuity among remaining enrollees, resulting in higher medical costs for health plans.
