During a featured session at Becker’s 3rd Annual Payer Issues Roundtable, Bob Tavernier, Sales Solutions Executive with Quest Analytics®, and Karen Tachian, Senior Director of Network Regulatory Operations with Health Care Service Corporation, unpacked recent survey data from 100 health plan executives.
The survey revealed how payer priorities are shifting under pressure from regulators, cost constraints and shifting member expectations. The conversation provided a rare inside look at how health plan strategies are evolving. The speakers also shared lessons from the data-integration partnership between their organizations. Quest Analytics® helps health plans ensure that healthcare networks are adequate, compliant and accessible.
Below are five takeaways from the session.
Note: Quotes have been edited for length and clarity.
1. Data Quality Is the Silent Strain on Network Strategy
Executives ranked provider cost and utilization data as “poor quality” and access-to-care data as only “moderate,” despite listing both as top priorities. “We spend a lot of time mining, sifting and working to understand our data,” Ms. Tachian said. “It takes a lot to get insights that you can take strategic steps or find solutions with.”
Public data, especially for network adequacy and quality, is often outdated or incomplete. This creates major challenges for payers trying to optimize networks while meeting regulatory expectations.
2. Regulators Are Turning Up the Heat
Compliance is no longer a box-checking exercise. “Gone are the days of audits at every 6 or 12 months,” Mr. Tavernier said. “State and federal regulators are conducting these quarterly.”
New mandates in Illinois, Oklahoma and New Mexico require health plans to validate “dormant” providers with no recent claims. Ms. Tachian emphasized that these policies, along with stricter wait-time and directory accuracy standards, are reshaping how networks must be built and maintained.
3. Network Design Is an Art, Not Just a Science
Designing high-performing networks requires more than data. “It’s like a recipe, but you’ve kind of got to put your own twist on it,” Ms. Tachian said. “If you’re in a rural area, your provider landscape looks really different than if you are in Metroland Chicago. You then have to look at your members. Who is your population pool? When you look at your members, who has the most clinical risk? Who has the least access to care?”
She described the balancing act as both art and science — especially in rural markets or under value-based care models.
4. Cost Pressures Are Real, But Strategic Investments Still Matter
Survey results suggested cost containment efforts for health plans may be focused more on administrative expenses.
Still, Ms. Tachian emphasized that strategic investments — particularly in technology and internal data capabilities — are key to long-term sustainability. “Sometimes savings aren’t gained by cutting something,” she said. “It’s more about your overall roadmap. It’s about where you want see growth, where do you want to see efficiencies and where do you want to see scale.
5. Start Small, Think Big
For health plans just getting started on the integration of performance metrics into their network strategy, Ms. Tachian advocated for pairing early wins with long-term strategic planning.
In addition to identifying annual priorities, Ms. Tachian advised making a strategic roadmap for the following three to five years.
“Many of these data concerns and data quality issues can’t be solved in a quarter or even in a year,” she said. “It’s really important to get aligned on what’s feasible and where your low hanging fruit opportunities are.”
Starting small doesn’t mean thinking small. With the right insights and tools, health plans can lay the foundation for impactful strategies that strengthen their network performance and design. Explore how Quest Analytics can support your efforts in building resilient, high-performing networks. Click here to learn more.
