At Becker’s Fall Payer Issues Roundtable in early November, payer and provider executives discussed the shifting realities facing health plans, from regulatory pressure and AI adoption to member experience and cultural inclusion. Leaders described an environment where operational complexity, new compliance expectations, and rapid digital change are converging.
Across sessions, executives shared how plans are adapting: building stronger partnerships with providers, investing in automation, and embedding equity and consumer focus into their business models. The conversations highlighted a shared goal: to simplify healthcare delivery while maintaining financial stability and member trust.
Here are 10 takeaways from the roundtable:
1. Regulatory friction heightens around the ACA and Medicaid. Insurers expect significant membership declines due to the enhanced ACA subsidy expiration next year. Even if a last-minute agreement is reached, many rates have already been locked in, meaning any adjustments would likely be delayed until 2027. Medicaid leaders are warning of new coverage gaps as federal work requirements and redeterminations return to the policy agenda. Many Medicaid members are employed but face barriers proving eligibility due to digital divides and language access issues. Plans are responding by funding navigators and automating verification systems to preserve coverage.
“I would suggest to you that right now we are in the eye of the storm,” said 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.”
2. The regulatory recalibration of Medicare Advantage. CMS’s heightened oversight of risk adjustment, coding, and audits is reshaping how plans define compliance. Rather than maximizing capture, payers are emphasizing accuracy, documentation quality, and audit readiness. Shared accountability between clinicians and coding teams is replacing the siloed model of the past. For forward-looking organizations, compliance is becoming a strategic advantage.
“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,” said Kenric Murayama, MD, executive vice president and chief health officer, Hawaii Medical Service Association.
3. AI adoption as an operating model. Health plans are increasingly prioritizing the integration of artificial intelligence and digital tools into both their internal processes and external offerings. They are adopting platform-based AI strategies to connect workflows, cut administrative costs and scale automation. But the transition isn’t always easy.
“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,” said Krystal Revai, MD, associate chief medical officer, Health Alliance Medical Plans.
Maintaining a human-centered approach, with the member at the core of their strategies, remains a critical focus for health plan executives throughout digital transformation.
4. Prior authorization and data quality are top priorities. Prior authorization reform is essential over the next few years and health plans need quality data to develop the right strategy. Executive teams are working on solutions to reduce prior authorization friction through AI technology and collaborations with provider organizations. This is especially important as scrutiny on healthcare processes and costs tightens.
“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,” said Joris Prikken, associate vice president of strategy advancement at Humana. “There are a couple of things we’re actively working on in terms of unnecessary prior authorizations. 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.”
5. Payer–provider relationships are becoming transformational. There is a “third culture” emerging between payers and providers, one built on transparency, data sharing, and aligned incentives. Successful collaborations, such as the Sutter Health and SCAN Health Plan partnership, embed shared P&Ls and joint governance. Leaders agreed that digital tools must be embedded within care models, not bolted on, and reinforced with human touchpoints and financial incentives to drive engagement.
“We hope this is the impetus for change across the industry because especially in the Medicare Advantage space, older adults deserve more,” said Karen Schulte, president of Medicare at SCAN Health Plan. “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.”
6. Health equity is evolving from initiative to infrastructure. Executives agreed that health equity is no longer a project — it’s an operating requirement. Plans are embedding equity across HR, finance, network design, and clinical workflows, often guided by system readiness frameworks. Medicaid and Medicare Advantage payers are partnering with community-based organizations to close access gaps in housing, maternal health, and transportation. Equity must be measurable, funded, and built into every function of the plan for it to be sustainable.
“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?” said Tamara Smith, vice president of health equity and social impact at Humana
7. Value-based care is in execution mode. After a decade of experimentation, value-based care is entering a phase focused on delivery, data-sharing, and interoperability. Despite the many headwinds and challenges that have hindered value-based care performance and adoption, it remains the right priority for many health plans. There’s no better option on the table for plans hoping to achieve long-term cost stabilization while improving health outcomes. The differentiator isn’t the contract; it’s how well technology and people align in execution.
“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,” said Jessica Hohman, MD, associate chief medical officer, value-based care, trend and network at Cigna Healthcare.
8. ‘Innovation’ is going back to the basics. Executives called for a return to fundamentals: evidence-based care, behavioral health integration, and medication optimization. The next generation of plan design will rely on local customization, telehealth-enabled primary care, and simpler benefit structures. AI-driven personalization and self-service are improving member engagement and simplifying complex healthcare experiences. “Shiny” pilots that aren’t supported by strong data or provider alignment are being replaced by hyper-focused, replicable models rooted in community realities.
“I don’t think that innovation is always a shiny new penny,” said Caroline Carney, MD, CEO of Magellan Health. “Sometimes innovation is taking a tried and true model and actually making it work in a variety of clinical settings.”
9. Health plans are elevating consumer centricity. The next wave of chronic care management will center on segmentation and personalization. Combining clinical, behavioral, and social data allows plans to anticipate needs and intervene earlier, often in the home. Engagement strategies are getting simpler and more human, with seniors preferring text messages, home visits, and culturally relevant communications over complex portals.
“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,” said Sam Melamed, CEO of NCD.
10. Cultural competency is an imperative. Cultural alignment is becoming both a growth strategy and a compliance necessity. Regional plans are demonstrating how multilingual benefit design, community hubs, and culturally attuned provider networks can drive both satisfaction and retention. CMS is expected to embed language access and SDOH performance into Star Ratings and contract renewals by 2030. Health plans that can operationalize inclusion will hold a lasting advantage.
“We have a Medicare plan focused on cultural competency and sensitive care,” said Martina Lee Strickland, chief growth officer at Clever Care Health Plan. “As the population gets more diverse, our focus is supporting the folks with cultural sensibility and also linguistic isolation.”
