Payer executives are keeping a close eye on a shifting regulatory environment and ongoing provider shortages.
The 16 executives featured in this article are speaking at the upcoming Becker's Payer Issues Roundtable events. The fall roundtable will take place Nov. 4-6 at the Swissotel in Chicago. The spring roundtable will take place April 28-29 at the Hyatt Regency Chicago.
If you have any questions about attending the event in November or April, contact Heidi Simon at hsimon@beckershealthcare.com.
Note: Responses have been lightly edited for length and clarity.
Question: What are the big headwinds you're watching?
Regulatory changes
Stacy Edgar. CEO and Founder of Venteur (Berkeley, Calif.): A critical headwind right now is the political landscape, particularly as elections approach. Healthcare remains a contentious issue, often influenced by the politics of fear, with the ACA serving as a lightning rod for debate. This current discourse can create a misleading perception about the ACA, making it seem like it hasn’t evolved or that it doesn’t offer sufficient value for businesses and their employees. Navigating these perceptions while promoting the benefits of ICHRAs will be essential for market growth and acceptance.
Jack Hooper. CEO and Co-Founder of Take Command Health (Richardson, Texas): The biggest headwinds we're facing is status quo thinking. The reality is the group health insurance market isn't working but people and stakeholders keep clinging to it. ICHRA takes a lot of change, from clients and industry stakeholders but will create a more sustainable marketplace.
Aric Sharp. Divisional CEO, Value-Based Care at Clover Health (Franklin, Tenn.): Across the Medicare Advantage space, we are seeing payers face increasing utilization, financial impact from the Inflation Reduction Act, and effects from regulatory changes such as the implementation of V28. Collectively, these headwinds are leading many payers to retreat from select markets while also modifying their benefit plan designs for 2025. However, these challenges also present an opportunity for well-performing innovative payers, and that will be interesting to keep an eye on during the upcoming [annual enrollment period].
Jennifer Shermo. Chief Growth Officer of Security Health Plan of Wisconsin (Marshfield): There is no lack of headwinds to watch as a healthcare leader in today’s environment. Regulatory changes and uncertainty continue to be at the top of the list as our government-sponsored plans continue to evolve, such as Medicare, Medicaid and the ACA. Additionally, the rising cost of healthcare and inflation are of significant concern and are compounding on top of regulatory changes and their administration expenses. Our challenge is to continually find ways to control costs while maintaining quality care and member satisfaction.
Alessa Quane. Chief Insurance Officer of Oscar Health (New York City): The important role enhanced tax credits play – especially for the most vulnerable populations – simply can not be overlooked. More than 19 million ACA enrollees with incomes below 400% of the Federal Poverty Level depend on these tax credits to make health insurance affordable. If they were to expire, it would significantly reduce the choices available to millions of ACA enrollees and force people to make financial choices between healthcare and their basic necessities. Many would also be forced to choose less benefit-rich plans just to maintain their out-of-pocket premium contributions. This could lead to inadequate coverage and higher out-of-pocket costs in the long run. As a bipartisan issue, Congress has a strong incentive to find a permanent solution to protect equitable access to health coverage for our most vulnerable populations.
Krischa Winright. President of Medicare Advantage for Blue Cross Blue Shield of Michigan (Detroit): In the Medicare Advantage industry, health plans across the country are facing similar challenges from the rising cost of healthcare to increased utilization — all while navigating funding pressure and escalating performance expectations. These challenges are compounded by a growing senior population, with nearly a quarter of Americans shifting to age 65 or older by 2030. Health plans that are going to be most successful in this new environment are those that commit to accelerating their performance drivers, strive for innovation and renew their commitment to supporting the quality of care and service for their senior members — that includes specifically doubling-down on work to support and partner with the healthcare provider community.
Affordability
Joe Glinka. Director of HealthChoices at Highmark Wholecare (Pittsburgh): We are intensely focused on the increased acuity and associated medical cost of our plan's enrollment resulting from the Public Health Emergency's continuous enrollment unwinding
process. Our experience is similar with that of other Medicaid managed care organizations in numerous states across the country.
Medicaid enrollment nationally grew by more than 20 million people during the PHE due to the provision of enhanced federal matching funds to states to maintain continuous Medicaid enrollment. The unwinding of continuous Medicaid enrollment is an unprecedented event for which no one could have accounted for accurately in the context of increased acuity.
As experienced in other states, we have seen 'healthier' people get redetermined out of Medicaid (the leavers). Those remaining (the stayers) historically have a more complex health status. We are experiencing impactful trends in professional, outpatient volume and overall pharmacy benefit
utilization.
Another issue we’re monitoring within pharmacy is the unanticipated escalation in the utilization of GLP-1 weight management medications used in the treatment of diabetes and obesity. In the interest of accessibility, there are regulatory limits to the degree of prior authorization protocols we can leverage to bring greater stability to the utilization of these medications, especially in the treatment for obesity.
These two items are significantly impacting the viability of MCOs in the current year. They stand to have a compounding financial impact for MCOs unless their respective state regulators review the actuarial soundness of current Medicaid MCO rates and proceed with adequate mid-year rate adjustments where warranted.
Tom Grote. CEO of Banner | Aetna (Phoenix): The rising demand for expensive treatments like GLP-1s and genetic therapies poses a significant challenge in healthcare. As these interventions become more common, finding a sustainable path will mean navigating the tension between cutting-edge treatments and affordability. This is especially true as reimbursement models shift toward value-based care, which focuses on optimizing outcomes.
Jeremy Wigginton, MD. Chief Medical Officer of Capital Blue Cross (Harrisburg, Pa.): Healthcare affordability issues create the biggest headwinds we currently face. With labor costs rising, emergence of new clinical trends such as GLP-1 utilization growth, and increased prevalence of behavioral health conditions, we are highly focused on working with clients and providers to ensure the highest quality services and best access at the most affordable price for our members. We can counteract these headwinds by helping our members navigate the complex healthcare system, educating them on the highest-quality care options, and directing them to programs and benefits that lower their out-of-pocket costs while helping them manage their health optimally. We'll also be expanding our collaboration with provider partners on value-based care models and improving health outcomes.
Access and provider availability
Sonny Goyal. Senior Vice President, Diversified Business Group at Blue Cross NC (Durham, N.C.): Though at times it feels a distant memory, COVID's lingering impacts are a continued headwind to our healthcare system. The mental health crisis that arose out of the pandemic, exacerbated by the isolationism brought on by remote work and learning that for many has continued, is far from being adequately addressed. There are too few mental health providers to meet the need, and the downstream impacts of inflation resulting from COVID have also made health fiscally unattainable for some. Many value-based payment models lack the financial incentives to promote whole-person care including behavioral health. By doing things like integrating behavioral health with primary care in value-based models, providers and payers can collaborate to counteract these headwinds.
Dennis Hillen. Senior Vice President of Market Leadership of Oscar Health (New York City): The healthcare industry has been grappling with provider burnout for years. We are particularly concerned about the increasing workload, administrative burdens and emotional toll that providers face. These factors contribute to high turnover rates, reduced job satisfaction, and ultimately, a decline in the quality of care delivered to patients –– which is counter to the ultimate goal that aligns us all. At Oscar, our technology helps reduce the burden on providers, whether that’s explaining payments or helping clinicians navigate dense medical records. All of our efforts are aimed at enabling them to better focus on clinical care.
Edward Juhn, MD. Chief Quality Officer of Inland Empire Health Plan (Rancho Cucamonga, Calif): The Inland Empire is larger than 10 U.S. states combined, while our provider-to-member ratios are among the lowest in California. To ensure our 1.5 million members receive their best possible health outcomes, IEHP focuses on innovative and transformative partnerships in our region. This includes supporting our local medical schools with 50 full-ride scholarships per year where upon graduation, these new providers will serve in our communities. It also includes our commitment to the social drivers of health in our region, seen through the growing number of community health workers who connect directly with our members to manage chronic conditions, address preventive care issues, and reduce barriers in accessing health services. We know this can't be done alone, but through the dedication and perseverance of our team members, providers, and community.
Jim Laughman. President, Intellectual and Developmental Disabilities Solutions at AmeriHealth Caritas (Philadelphia): One of the biggest headwinds for our industry is the shortage of behavioral health clinicians. Much of our business is serving Medicaid enrollees, and nearly 40% of non-elderly Medicaid enrollees have a behavioral health challenge. But it is becoming increasingly hard for these members to obtain behavioral healthcare services, especially in rural areas.
While bringing more professionals into this field will take time, a potential short term remedy is easing access to telehealth by states adopting a uniform set of guidelines. The COVID-19 pandemic demonstrated the potential of telehealth to overcome access barriers by allowing patients to obtain behavioral healthcare even from a distance. But each state can have its own approach to telehealth in terms of what health insurers are required to cover, how patients can access it, and how clinicians can bill for telehealth services. By making these rules uniform across states, patients will have an easier time obtaining care from a clinician in another state if one isn’t available near them. And this will help overcome the shortage of behavioral healthcare in many parts of the country.
Doba Parushev. Managing Partner at Healthworx (Baltimore): Over the past few years, the influx of new healthcare solutions has overwhelmed potential customers, including payers, providers, pharma companies, and individual consumers. An example of this issue is the rise of specialized point solutions targeting specific problems like diabetes or cardiovascular health. Although initially well-received, users are now struggling to quantify the impact of specialized, in-depth support, and many stakeholders who have integrated multiple solutions have found it both complex and costly. This has led to "point solution fatigue," causing customers to be more selective, setting stricter performance targets and reducing the number of solutions they adopt. While this puts pressure on existing solutions, the increased clarity from customers may ultimately improve the quality of those that survive.
Ray Prushnok. Executive Director, UPMC Center for Social Impact at UPMC Health Plan (Pittsburgh): Medicaid rate adequacy is one of the biggest threats to the emerging consensus on health equity and the role of payers in solving for health-related health social needs. Organizations like UPMC Health Plan have made strides in going upstream, braiding with public benefits and human services, and in promoting self-sufficiency. Our efforts to demonstrate the impacts of programs like SNAP, wrapping supportive services around housing for people experiencing homelessness, leveraging community health workers at community-based organizations, food as medicine and helping members attain employment show promise. While in their nascency, the results are positively clear – we see lower costs, and improved quality, and improved satisfaction – scaling such programming in communities facing deep inequities is threatened by an imperative to adequately fund core benefits.
Shelley Turk. Divisional Senior Vice President of Illinois Health Care Delivery at Health Care Service Corp. (Chicago): Seeing around corners is a necessary part of my role as we work to maintain widespread access, affordability and quality. I watch U.S. and global economic conditions, core inflation, Federal Reserve rates and the unemployment rate. Provider headwinds often become payer headwinds. Inflation, unemployment, higher labor and materials costs, and other economic challenges can lead to requests for rate increases, provider consolidation and reorganization, and strategic provider market exits or terminations. The decisions we make on value-based care and negotiated rates affect the cost and access to care for our employer groups and their employees. Maintaining and growing access to government program network providers is also critical to our membership. We work with provider groups to help underserved communities as well as our commercial population. Our industry must remain sensitive to economic headwinds due to the size, scope and individual needs of participants in the healthcare system. We do that by anticipating changes to the overall economic picture to maintain health care stability for our members, our groups and our employees.