The payer-provider relationship is continually evolving. Becker’s connected with 13 health plan leaders to find out which part of that relationship they would change.
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Editor’s note: Responses have been lightly edited for clarity and length.
Question: If you could redesign one part of the payer–provider relationship to improve quality and reduce friction, what would it be and why?
Jennifer St. Thomas. Senior Vice President of Commercial and Medicare Markets, Mass General Brigham Health Plan (Sommerville, MA): As part of an integrated health system, we have unique opportunities to combine comprehensive care and coverage to support a variety of care journeys. By leveraging population health approaches, clinical expertise, and coordinated care teams — we can support care at the right time in convenient settings to deliver a connected healthcare experience. For example, we’re currently deploying integrated care models to deepen our support for our members—demonstrating how we’re already bringing this vision to life
Sharon Williams. Chief Executive Officer, University of Michigan Health Plan (Lansing, MI): I would have the US adopt a one fee schedule like Medicare, for example, so there would be more transparency in rate negotiation and to promote health equity among different insurance products. No more charge masters, unique bundles, Commercial, Medicaid, Medicare and ACA products would all use a one fee schedule to start reducing the administrative burden. The fee schedules would be based on the provider cost structure.
Tatyana Kanzaveli. Chief Executive Officer, Open Health Network (Mountain View, CA): If I could redesign one part of the payer–provider relationship, I’d start by blowing up prior authorization as we know it. Instead of today’s maze of faxes, portals, and denials, I’d replace it with a shared, real-time “care rail” that both payers and providers run on — a longitudinal, AI-powered patient story that automatically checks coverage, flags risks, and quietly green-lights most routine care in the background. On top of that shared rail, both sides would co-design outcome-based contracts using the same live data on quality, equity, cost, and patient experience. We’re seeing early fragments of this in real-time prior auth, FHIR, and AI tools, but no one has truly turned it into a co-owned operating system — and until we do, we’re leaving trust, capacity, and better care on the table.
Mike Costa. Senior Vice President of Provider Network and Population Health, EmblemHealth, Inc. (New York, NY): A redesign that could meaningfully improve quality and reduce friction equips clinicians and care teams with timely, patient-specific signals – quality metrics and incentives, utilization risk, formulary options, and out-of-pocket costs – in the EHR at the point of encounter. These are signals they can act on during the encounter, but, more importantly, they can verify that those actions improve outcomes, enhance experience, and lower medical cost spend. A framework that integrates decision support in EHR, prioritizes cost transparency, and provides actionable data and feedback can deliver improved quality outcomes. Ultimately, it’s about creating a framework that enables providers to close care gaps immediately, eliminates the back-and-forth on coverage or cost, and aligns incentives and transparency.
Dawn Maroney. President, Alignment Health (Orange, CA): If we could redesign one part of the payer–provider relationship, I would create true shared ownership of Medicare Stars performance, especially in areas that matter most to seniors—access to care, timely follow-up, and coordinated support across the system. Today, payers shoulder most of the accountability, while some exceptional health systems also invest deeply and treat Stars as a clinical priority. But this level of alignment is not universal, and payers must step up by giving providers clearer data, simpler workflows, and incentives that make quality and member experience actionable at the point of care. When both sides are equally accountable and equipped to improve Stars, access, and coordination, friction decreases, trust grows, and seniors receive the proactive, high-quality experience they consistently tell us they value.
Brett Bingham. Chief Network Development Officer, Banner Plans and Networks (Phoenix, AZ): If I could redesign one part of the payer–provider relationship, I would align financial incentives around the outcomes that matter most—resolving conditions, closing care gaps, and improving members’ health trajectories. Some payment models reward units of service rather than actual progress in a member’s health, creating friction and misaligned priorities between payers and providers. I recognize this isn’t possible with all payment models, but we should strive to do better. At Banner, we are proving that when payments directly support care-gap closure and the full resolution of conditions, performance accelerates and trust deepens. Coupling these aligned incentives with easier data flow and meaningful EMR integration would further reduce administrative burden and give clinicians real-time visibility into what their patients need. When both sides win by delivering healthier members, collaboration becomes natural, and the system becomes measurably better for members.
Harlon Pickett, President, Eagle Care Health Solutions (Blue Bell, PA): If I could redesign one part of the payer–provider relationship, I would fundamentally overhaul prior authorization, turning it into a collaborative, data-driven process rather than a bureaucratic barrier.
Right now, prior authorization is one of the most significant sources of frustration for clinicians and patients, and one of the least effective tools for improving quality. It often delays care, increases administrative workload, and creates distrust on all sides. Yet at its core, the intent behind prior authorization is valid. The goal is to ensure that the right care is delivered at the right time and at the right cost. The problem is not the concept. The problem is the execution.
If payers and providers shared transparent data on quality, outcomes, and adherence to evidence-based guidelines, we could replace blanket prior authorization requirements with automatic approvals for high-performing providers and streamlined review processes for clear appropriate care. This type of redesign would eliminate unnecessary denials, reduce administrative waste, and allow payers to focus oversight where it truly matters.
A collaborative prior authorization model would reduce friction, rebuild trust, and improve the patient experience. It would also allow both sides to concentrate on delivering high-value care rather than managing paperwork.
Michael Kobernick, MD. Senior Medical Director of Commercial Markets, Blue Cross Blue Shield of Michigan and Blue Care Network of Michigan (Detroit, MI): While prior authorization is important to validate medical necessity and the appropriateness of services and prescriptions, we understand there are areas for improvement. By continuously innovating and reimagining prior authorization to make it simpler, faster, transparent and more effective for Blue Cross Blue Shield of Michigan’s members and provider partners, we can dramatically reduce administrative waste while ensuring patients receive the right care at the right time. Since last year, Blue Cross has made a number of enhancements to the prior authorization/referral process that make it easier for our members to understand and navigate. In partnership with the Blue Cross Blue Shield Association and AHIP, many insurers across the country have agreed to standardize, streamline and dramatically improve the systems we use to authorize some health care procedures and treatments.
Jeff Bak. President and Chief Executive Officer, Imagine360 (Wayne, PA): Healthcare reimbursement in the commercial market is confusing and lacks transparency. Prices vary widely and are far higher than benchmarks like Medicare. In fact, commercial costs often run more than 250% of Medicare rates and are even higher in many states. This uncertainty leaves employers and employees facing unexpected bills, which hurts trust and efficiency. A fair, transparent reimbursement model would help employers control costs and keep care affordable and accessible. It also ensures providers receive fair, timely payment.
Alexander Ding, MD, MBA, Deputy Chief Medical Officer, Humana (Louisville, KY): The payer-provider relationship needs to evolve even more around interoperability for real-time data sharing. Patients need simple, universally transferable, secure medical records, and providers need actionable data with efficient population health management workflows. When providers and payers have the right information, we become partners in helping patients have better health. Seamless information sharing is also the foundation for value-based care models, which results in less abrasion, more preventive care, more care gaps closed, and more opportunity to deliver holistic care.
Ria Paul, MD, Clinical Associate Professor, Stanford University School of Medicine; Chief Medical Officer, Santa Clara Family Health Plan (San Jose, CA): Alignment on quality metrics for payer and provider, so there is commonality on areas of focus. It will be very helpful for both the payer and provider to double down on metrics that has similar clinical and financial significance. Payers can collaborate, incentivize providers for improvement of quality metrics that will enable improving their ratings NCQA or other regulatory agencies. Payers and providers must work in tandem and not in silos to maximize on improvement in population health.
Dan Zohorsky. Managing Partner, Healthworx (Baltimore, MD): I believe the primary driver of friction in the payor-provider relationship is misaligned incentives. While there are secondary contributors (interoperability challenges, lack of trust, lack of standardized documentation), they are in many ways rooted or derived from the conflicting economic incentives that consistently drive operating systems and behaviors.
Payor and provider incentives can be aligned with value/outcome-based constructs that include the following elements: focused on a handful of outcome measures that matter, timely sharing of data (both prospectively to inform clinical interventions and performance reporting), collaborative and transparent joint operating committees. While there are additional elements, as well as nuance to the points above, I believe that adoption of these constructs can measurably reduce the friction between payors and providers, reduce the abrasion the members/patients experience caught in the middle, and improve the quality of care.
Kevin Knight. Chief Marketing Officer, Sidecar Health (El Segunda, CA): Doctors should be able to set their own prices — just like every other service provider in every other industry. When doctors don’t know what they’ll get paid and patients don’t know what they’ll pay, we can’t be surprised that healthcare inflation is so high. Prices grow fastest in the dark. Let’s shine a light on them.
Ty Wang, Co-Founder and Chief Executive Officer, Angle Health (San Francisco, CA): I would rebuild how data is shared across the ecosystem. Today, both sides operate with siloed and difficult-to-access data, which drive unnecessary friction and reactive and/or delayed care. Shared standards and modern intelligence platforms will enable more advanced privacy protections, greater transparency, better care journeys, and less administrative burden. Most importantly, it can drive true alignment on incentives around delivering higher-quality, more affordable care for consumers.
Howard Weiss. VP Government Affairs, EmblemHealth, Inc. (New York, New York): Quality of care begins with coverage and affordability, because if people cannot afford health insurance, they are unlikely to get access to preventive and other services so crucial to improving their health. Policymakers in Washington, DC and around the country are now extremely focused on these issues. Health plans, physicians, hospitals, and other providers should put differences aside and work together to explain to policymakers the importance of ensuring individuals have affordable access to health insurance. All of us have a stake in ensuring families don’t risk the prospect of financial catastrophe by being uncovered or not covered adequately to meet the high cost of care.
Richard Greene. President, Clever Care Health Plan (Huntington Beach, CA): If I could redesign one part of the payer-provider relationship, it would be how we share critical health data, so providers have the information they need to deliver personalized, culturally competent care. Today’s health IT systems are often delayed or fragmented, making it hard for payers and providers to deliver proactive, preventative care that keeps people healthy. In an ideal world, we would have real-time data sharing integrated directly into providers’ workflows, giving them actionable insights in the moments that matter – such as hospital admission – while health plans receive timely clinical updates in return. What I like most about this approach is how it transforms the relationship from oversight to genuine partnership, enabling payers and providers to work together and drive better health outcomes for the members we serve.
Pritee Subramany. Vice President of Product Management, Highmark Health (Pittsburgh, PA): If I could redesign one part of the payer–provider relationship to improve quality and reduce friction, I would remove the member as the intermediary when they are trying to use their health insurance to get care. In current state, there’s too much burden unintentionally placed on individuals to navigate a fragmented ecosystem. That complexity creates delays and frustration at the very moment people need clarity and support. By taking the member out of the middle, we create the foundation for a more seamless experience that can promote better health outcomes. When payers and providers align on care pathways, we reduce friction, strengthen trust and help people receive the right care at the right time with fewer barriers.
