12 opportunities payers can seize next year

Payers have the opportunity to make strides on equity and care outcomes in the next year. 

The 12 executives featured in this article are speaking at Becker's Spring Payer Issues Roundtable. The spring roundtable will take place April 28-29, 2025 at the Hyatt Regency Chicago.  

If you work at a health plan and would like to join as a speaker in April, contact Randi Haseman at rhaseman@beckershealthcare.com

Note: Responses have been lightly edited for length and clarity. 

Question: What is the biggest opportunity for payers in the next 12 months?   

Damanjeet Chaubey, MD. Vice President of Clinical Affairs at Clover Health (Franklin, Tenn.): Balance the cost and quality equation to deliver value. Alignment within organizations and a synergistic approach is crucial to offset competing priorities and deliver quality care. The population is getting older, innovations in science and technology are expensive, and the medical and social needs of aging members driving utilization needs better understanding with timely interventions.   

Akrom Hossain. Senior Director of Health Care Management at Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma & Texas (Chicago): There are numerous opportunities for payers to improve member health outcomes and support providers in delivering quality care. I foresee the increasing use of personalization in healthcare to make resources accessible to both members and providers through their preferred channels, precisely when they are needed the most. Payers have the opportunity to integrate best-in-class point solutions and technologies in a holistic, coordinated manner to promote whole health and wellness.

Michael Hunn. CEO of CalOptima Health (Orange, Calif.): Network adequacy could be positively impacted by emerging technologies (AI) that have the potential of improving PCP efficiency thereby offsetting the number of expected physician retirements. Additionally, same-day treatment authorizations and claims payments are entering the realistic realm of tech possibilities. The opportunity will best be taken by looking round both the corner and the curve of enterprise "dynamic" technologies.

Michael Kobernick, MD. Senior Medical Director, Health Plan Business at Blue Cross Blue Shield of Michigan (Detroit): [The] biggest opportunity is to provide support to members during difficult care journeys through care management. 

Hilary Marden-Resnik. President and CEO of UCare (Minneapolis): In the next 12 months, payers have both an opportunity and a responsibility to be a source of stability in a time of dramatic change. For example, payers must help members understand the Medicare Part D changes going into effect in 2025. Payers also must advocate for the continuation of the tax credits for the individual market that expire at the end of 2025, to ensure marketplace stability and affordability. If those tax credits expire, enrollees will face increased premiums that may be unsustainable for many of them in 2026. Finally, payers must support efforts to re-enroll individuals who lost Medicaid coverage for procedural reasons during the redetermination process. As payers, we are in a unique position to help members navigate change in a tumultuous health care environment impacted by regulatory changes, rising costs and provider network disruptions.

Ria Paul, MD. Chief Medical Officer at Santa Clara Family Health Plan (San Jose, Calif.):  In this rapidly changing healthcare landscape, the world of payers is also changing fast. It is imperative for payers not to be working in silos anymore but in tandem with the care-delivery side and be in alignment. As AI is transitioning to becoming a major change agent, payers need to open to adopting AI in areas of operations where great efficiency and accuracy will be helpful like claims, revenue cycle, also in clinical areas of understanding the patient population based on risk stratification. Another major area that payers need to work on is care coordination to enable line of sight across the care continuum of the member with a focus on keeping members healthy and away from acute care settings.

Chandni Sud-Thavakumar, EdD. Vice President, Performance Operations at Mass Advantage (Worcester, Mass.): The biggest opportunity for payers will be focusing on [the] whole health of their members, which would include a larger collaboration between the network, the payer and the membership. This shift would encompass the move toward value-based care models with a larger emphasis around specialty care. Retention of membership and experience with both the payer and the network will be key in this shift.

Balance the cost and quality equation to deliver value. Alignment within organizations and a synergistic approach is crucial to offset competing priorities and deliver quality care. The population is getting older, innovations in science and technology are expensive, and the medical and social needs of aging members driving utilization need better understanding with timely interventions.

Philip Randall. Director, Population Health and Community Programs at Banner|Aetna (Phoenix): Determine how to better integrate and utilize virtual behavioral health services in health plans. There are great offerings out there that can make an impact with members and improve health literacy, chronic condition self-management and more. The challenge remains around getting those affordable and effective virtual services to the members who need it most. In this area, payers have an opportunity to thoroughly research, develop and execute new and better strategies.

Ilan Shapiro, MD. Chief Health Correspondent and Medical Affairs Officer and Senior Vice President at AltaMed Health Services (Los Angeles): We all need health. From prevention to treatment, the communities must engage with healthcare plans. The following 12 months will be defined by the integration of what would happen on Nov. 5. This could change the consistency that we have had in the past six years.

Anthony Thompson. Senior Vice President, Healthcare Network Strategy at CDPHP (Latham, N.Y.): Over the next 12 months, one of the biggest opportunities will be in the advancement and utilization of machine learning and generative AI in designing alternative payment models and value-based contracts. From my perspective, these technologies will help streamline payment models by leveraging predictive analytics to identify patterns and customize payment models based on more selective and actionable criteria. Generative AI, particularly in processing and interpreting unstructured data like medical record notes, can help provider-payer partnerships identify cost-effective action plans for member populations that can be aligned with value-based care initiatives. By streamlining the analysis of patient histories and social influencers of health, we can better predict which patients are at risk of chronic conditions and prioritize preventive care. This tech supported approach will help strengthen the partnership between payers and providers, prioritizing patient outcomes and cost management, creating more sustainable value-based care models that further the ability of providers to focus on quality of care rather than fee-for-service constraints.

Johanna Vidal-Phelan, MD. Chief Medical Officer, Quality and Pediatrics at UPMC Health Plan (Pittsburgh): As I reflect upon the many opportunities ahead for payers, I believe that the biggest opportunity in the next 12 months lies in advancing health equity. As key stakeholders in the healthcare ecosystem, payers have a pivotal role in helping to ensure that all individuals, regardless of their background, have access to quality care.

To achieve this, payers should focus on incorporating health equity goals into value-based care programs. By aligning incentives with health equity outcomes, payers can address disparities and promote better health for underserved populations. Additionally, engaging with community-based organizations is crucial. These organizations have deep insights into the unique needs of their communities and can help tailor interventions that are culturally and contextually appropriate. This commitment to achieving health equity in our communities is not just a short-term goal but a long-term [one], sustained effort that requires continuous dedication and collaboration.

By prioritizing health equity, payers can not only improve health outcomes but also build trust and strengthen relationships within the communities they serve. This trust is essential for fostering a sense of connection and mutual respect, which are critical for the success of any health initiative. Moreover, focusing on health equity can lead to a more efficient allocation of resources, as it helps identify and address the root causes of health disparities. This approach helps ensure that interventions are targeted and effective, ultimately leading to a more equitable and effective healthcare system. By working together and maintaining a commitment to health equity, payers can create a healthcare environment where everyone has the opportunity to achieve their best possible health.

David Wang, MD. Chief Operating Officer of Mass Advantage (Worcester, Mass.): Margin pressures across the board are recalibrating enthusiasm for delegated risk arrangements. Now is a time for payers and providers to come together and ask: What must we build, buy, or partner to sustainably contain the total cost of care? Value-based care is a duet between contracting and care transformation. 

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