Introduction
The healthcare payer landscape is experiencing unprecedented transformation as industry leaders confront converging challenges in regulation, technology, and member expectations. At Becker’s Fall Payer Issues Roundtable in early November, payer and provider executives gathered to discuss the shifting realities facing health plans across the United States.
The discussions revealed an industry at an inflection point, where operational complexity, new compliance expectations, and rapid digital transformation are simultaneously reshaping business models. Leaders described strategies for navigating this turbulent environment while maintaining financial stability and member trust.
Throughout multiple sessions, executives emphasized the critical importance of building stronger partnerships with providers, investing strategically in automation and artificial intelligence, and embedding equity and consumer focus into every aspect of their operations. The overarching theme centered on simplifying healthcare delivery without compromising quality or access.
Regulatory Landscape and Compliance Pressures
ACA and Medicaid Face Heightened Scrutiny
Health plans are preparing for significant membership disruptions stemming from the extended Affordable Care Act subsidy expiration scheduled for next year. Industry executives anticipate substantial coverage losses, particularly because rate structures have already been locked in for the upcoming period. Even if policymakers reach a last-minute agreement to extend subsidies, any adjustments would likely be delayed until 2027, leaving many members vulnerable to coverage gaps.
Medicaid programs face parallel challenges as federal work requirements and redetermination processes return to the policy agenda. Many Medicaid enrollees are employed but struggle to provide adequate documentation proving eligibility due to digital literacy barriers and language access limitations. Health plans are responding proactively by funding community navigators and deploying automated verification systems to help preserve continuous coverage for vulnerable populations.
“I would suggest to you that right now we are in the eye of the storm,” explained Ceci Connolly, president and CEO of Alliance Community Health Plans. “The pace of change is slow until it is unbelievably fast. I think we’re right now at the intersection of the super slow and then zoom, it’s getting really crazy fast. That’s the case both in the markets and also from a regulatory perspective.”
Medicare Oversight Evolution Drives Strategic Compliance
The Centers for Medicare & Medicaid Services has intensified oversight of risk adjustment methodologies, coding accuracy, and audit processes, fundamentally reshaping how health plans approach compliance. Rather than focusing solely on maximizing risk score capture, payers are emphasizing documentation quality, coding accuracy, and comprehensive audit readiness.
This regulatory recalibration is driving a cultural shift within health plans. Shared accountability models between clinical teams and coding specialists are replacing traditional siloed approaches. Forward-thinking organizations recognize that robust compliance frameworks represent a strategic competitive advantage rather than merely a defensive necessity.
“We put a lot of emphasis on stars and risk adjustment for Medicare and at least for us and many other health plans, it’s becoming increasingly challenging in a capitated payment model to drive the behavior that we need from the providers so that everyone can benefit,” noted Dr. Kenric Murayama, executive vice president and chief health officer at Hawaii Medical Service Association.
Technology Integration and Innovation
AI Adoption Transforms Operational Models
Health plans are rapidly integrating artificial intelligence and advanced digital tools into both internal operations and member-facing services. Organizations are adopting comprehensive platform-based AI strategies designed to connect disparate workflows, reduce administrative burden, and scale automation capabilities across the enterprise.
However, implementation challenges remain significant. Dr. Krystal Revai, associate chief medical officer at Health Alliance Medical Plans, cautioned: “I think that the next three to five years is going to be a time of what might be painful growth. There’s going to be a lot of innovation; there’s going to be probably almost as many missteps.”
Despite these obstacles, health plan executives emphasize the importance of maintaining human-centered design principles throughout digital transformation initiatives, ensuring members remain at the core of all strategic decisions.
Prior Authorization Reform Accelerates
Prior authorization processes have emerged as a critical priority for health plans navigating increasing regulatory scrutiny and member dissatisfaction. Executive teams are developing comprehensive solutions leveraging AI technology alongside enhanced provider collaborations to reduce administrative friction.
Joris Prikken, associate vice president of strategy advancement at Humana, shared ambitious targets: “We are looking to meaningfully streamline the program just to ensure that people get timely access to the right care and we’re doing that together with other players in the industry as well. We’re striving to reduce outpatient prior authorization by one-third by January 1 of next year and then speed up the other ones that are still necessary.”
Quality data represents the foundation for effective prior authorization reform. Health plans are investing heavily in data infrastructure to support evidence-based decision-making and identify opportunities for process simplification.
Partnership Models and Care Delivery
Payer-Provider Relationships Become Transformational
Industry leaders described the emergence of a “third culture” bridging traditional payer-provider divides through transparency, comprehensive data sharing, and genuinely aligned financial incentives. Successful partnerships, exemplified by the Sutter Health and SCAN Health Plan collaboration, feature shared profit-and-loss accountability alongside joint governance structures.
Karen Schulte, president of Medicare at SCAN Health Plan, articulated the urgency: “We hope this is the impetus for change across the industry because especially in the Medicare Advantage space, older adults deserve more. Don’t normalize the abnormal and don’t tolerate complexity and fragmentation that we put into the marketplace that we know gets in the way.”
These transformational relationships require digital tools to be embedded within care delivery models rather than superficially added, with implementation supported by meaningful human touchpoints and financial incentives that drive sustained engagement.
Value-Based Care Enters Execution Phase
After a decade of experimentation and pilot programs, value-based care is transitioning into a delivery-focused phase emphasizing operational excellence, comprehensive data-sharing, and true interoperability. Despite numerous headwinds and adoption challenges, industry executives remain committed to value-based models as the most viable pathway toward long-term cost stabilization while improving member health outcomes.
Dr. Jessica Hohman, associate chief medical officer for value-based care at Cigna Healthcare, noted: “Everyone is trying to strike the right balance here and it’s important to acknowledge that fee for service will, for the time being at least, continue to persist and value-based care certainly holds a lot of appeal. How do we strike the right balance between providing the right incentives as we think about hospitals and health systems so they actually invest in disease management programs?”
The critical differentiator in value-based care success is no longer contract structure but rather how effectively technology platforms and care teams align in practical execution.
Member Experience and Equity
Consumer-Centric Strategies Evolve
The next generation of chronic care management centers on sophisticated segmentation and personalized interventions. Health plans are combining clinical, behavioral, and social determinants of health data to anticipate member needs and intervene proactively, often through home-based services.
Engagement strategies are becoming simpler and more human-focused, with senior members showing strong preferences for text messaging, home visits, and culturally relevant communications over complex digital portals. As Sam Melamed, CEO of NCD, emphasized: “We have to make sure that not only is the patient experience positive, but their customer experience has to be positive or they’re going to drop our plan.”
AI-driven personalization and intuitive self-service capabilities are enhancing member engagement while simplifying traditionally complex healthcare experiences.
Health Equity Becomes Operational Infrastructure
Health equity has transitioned from a discrete initiative to an essential operating requirement embedded across human resources, finance, network design, and clinical workflows. Medicaid and Medicare Advantage payers are developing strategic partnerships with community-based organizations to address social determinants of health, including housing instability, maternal health services, and transportation barriers.
Tamara Smith, vice president of health equity and social impact at Humana, explained: “What does it mean to actually advance health equity? For us at Humana, we are really thinking about what it means to look within our own system, to understand, are there ways we’re operating that could be contributing systematically to some of the inequities that we see?”
Cultural Competency Drives Competitive Advantage
Cultural alignment is emerging as both a member retention strategy and a compliance imperative. Regional health plans are demonstrating how multilingual benefit design, community health hubs, and culturally attuned provider networks drive both member satisfaction and plan retention.
CMS is expected to incorporate language access requirements and social determinants of health performance metrics into Star Ratings and contract renewal processes by 2030. Martina Lee Strickland, chief growth officer at Clever Care Health Plan, emphasized: “We have a Medicare plan focused on cultural competency and sensitive care. As the population gets more diverse, our focus is supporting the folks with cultural sensibility and also linguistic isolation.”
Innovation Returns to Evidence-Based Fundamentals
Health plan executives are calling for a renewed focus on proven fundamentals: evidence-based care protocols, behavioral health integration, and medication optimization strategies. The next generation of benefit design will leverage local customization, telehealth-enabled primary care, and simplified benefit structures.
Dr. Caroline Carney, president of behavioral health and chief medical officer at Magellan Health, noted: “I don’t think that innovation is always a shiny new penny. Sometimes innovation is taking a tried and true model and actually making it work in a variety of clinical settings.”
Unproven “shiny” pilot programs lacking strong data or provider alignment are being replaced by hyper-focused, replicable models rooted in community realities and member needs.
Key Takeaways
The Becker’s Fall Payer Issues Roundtable illuminated the complex transformation underway across the health insurance industry. Payer leaders are simultaneously navigating regulatory uncertainty, accelerating digital innovation, deepening provider partnerships, and embedding equity principles throughout their organizations.
Success in this evolving landscape requires health plans to balance competing priorities: maintaining financial sustainability while improving member experience, adopting advanced technology while preserving human connection, and meeting compliance requirements while driving operational efficiency.
The organizations that will thrive are those that can operationalize these principles at scale, creating seamless experiences for members while building sustainable business models capable of adapting to continued regulatory and market evolution.
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