Health plan leaders are no strangers to complexity, but the current moment feels different. Regulatory pressure, affordability concerns, the slow-moving shift to value-based care, and the operational weight of modernizing systems that were not built for today’s demands are all hitting at once — and leaders are having to make high-stakes decisions with imperfect information and shrinking margins for error.
Becker’s asked 11 payer executives to name a challenge they are currently navigating. The answers ranged from disputes over IDR process abuse and the lag between VBC investment and return, to building member trust in new markets and rethinking what it means to buy healthcare rather than just insure it.
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Editor’s note: Responses have been lightly edited for clarity and length.
Question: What is one challenge you’re currently navigating?
Jennifer Howard, MSN, RN. Lead Director of Value Based Care Provider Engagement for CVS Health Aetna (Hartford, Conn.): One challenge we navigate in value‑based care is the provider organization’s upfront cost required to improve outcomes, when the financial benefits are often realized years later.
While there are many challenges—such as managing total cost of care, taking on financial risk‑bearing contracts, and addressing social determinants of health—the lag between investment and return is one of the most difficult to overcome. Provider organizations want to improve outcomes to ultimately lower costs, but doing so requires significant upfront investment. That includes human capital, care management resources, and data analytics capabilities to identify gaps, leakage, and opportunities for improvement, to name a few. I often hear providers asking: How do we make the case for investing today when the savings may not materialize for several years? That tension can slow progress, particularly for organizations with tight margins.
One way to offset those upfront costs is through value‑based contracts that allow for gradual growth into risk. Starting with upside‑only models or shared savings gives organizations the runway to establish workflows at the point of care before assuming greater downside risk.
Another important lever is collaboration with the payer by leveraging payer data — such as claims insights, utilization patterns and predictive modeling — rather than immediately building costly in‑house analytics capabilities. Over time, providers can then optimize their own data infrastructure, including advanced analytics and AI, when the return is clearer.
Finally, having a well‑defined plan to regularly reevaluate performance — both operationally and contractually — is critical. Annual reviews of what’s working, what’s not, and how the payer‑provider partnership can evolve help ensure the strategy remains aligned and sustainable over time.
Uche Olekanma, MD. Vice President of Clinical Operations for Blue Cross Blue Shield of Arizona (Phoenix): One challenge I’m currently navigating is modernizing utilization management while maintaining trust with providers and members. As payers face increasing regulatory pressure, rising medical costs and clinician burnout, we’re working to move from traditional, transaction‑heavy utilization management to a more data‑driven, clinically nuanced, and collaborative model. That means reducing administrative burden where it doesn’t add value, aligning decisions with the latest evidence and guidelines, and using technology and physician‑led governance to make processes more transparent and consistent.
James Grana, PhD. Vice President of Value Based Care Programs, Network Development and Contracting for BlueCross BlueShield of South Carolina (Columbia): One challenge we are currently navigating is the growing misuse of the Independent Dispute Resolution process by certain providers, including high volumes of questionable filings and strategic batching that strain system capacity. These practices increase administrative costs and drive upward pressure on overall healthcare spending without improving care delivery or patient experience. Ultimately, this behavior is inflationary and not in the best interest of members and insureds, as it contributes to higher premiums rather than affordability and access.
Ruchika Talwar, MD. Medical Director of the Office of Episodes of Care Population Health and Urologic Oncology for Vanderbilt University Medical Center (Nashville, Tenn.): While there is clear momentum behind value-based care and more predictable cost structures across the market, many employer benefit designs still rely on fragmented networks and frameworks that reward volume over outcomes. That misalignment slows the adoption of innovative models like direct-to-employers bundled programs, including MyHealth Bundles, even when they demonstrate improved clinical outcomes, patient experience and cost transparency.
The challenge is redefining what value means in benefit selection and aligning incentives to support that. Scaling requires employers to rethink systems that weren’t designed with this approach in mind. At Vanderbilt Health, we’re spending a lot of time bridging that gap by creating offerings that integrate with existing benefits infrastructure while demonstrating the impact of adopting outcomes-based models.
Tiffany Kobashigawa. Director of Strategy, Sales and Service for LA Care Health Plan (Los Angeles): The primary challenge I am navigating is the strategic integration of AI-driven, digital-first tools to automate complex enrollment workflows, while simultaneously steering through provider directory lag issues happening at the time of enrollment. This lack of real-time automation has the potential to and often does cause both member and provider abrasion. As an organization, we are not unique in having provider directory management issues, it is a healthcare industry issue we are all grappling with. And we are actively working to improve our systems, focusing on leveraging tech solutions not just for efficiency, but as a bridge to improve member retention.
Christina Rassi. Chief Growth Officer. Evry Health (Dallas): The challenge I navigate most honestly is scaling fast without losing the human element that makes us different. Evry Health does not have decades of brand recognition — we have results, relationships, and a better product, and my job is to earn trust in a market built on legacy while ensuring that no employer or member gets lost in our growth. It is why our team mantra, ” Lead with people. Grow with purpose.” is not just a tagline — it is the standard I hold myself and my team to every single day.
Jonathan Baran. Co-founder and CEO of Self Fund Health (Madison, Wis.): I run Self Fund Health, an integrated health plan that Wisconsin employers use in place of traditional BUCA carriers to drive down healthcare costs.
From that vantage point, the challenge I keep encountering is that most employers still think they’re buying insurance, when what they need to be buying is healthcare.
Recently, we sent a Wisconsin member to Johns Hopkins for open-heart surgery at a bundled $76K (travel included). The same procedure in a Wisconsin hospital would have run $219K.
Insurance rents a PPO network and passes through whatever the hospital charges. Healthcare is a service you buy directly — a surgeon, a surgery center, a primary care team — with price and quality you can see before the procedure.
Hopkins is an employer who stopped buying insurance and started buying healthcare.
The hardest part of my job is helping more employers, brokers, and hospitals make that same shift.
Rhonda Mims. Executive Vice President and Chief Public Affairs and Risk Officer for AmeriHealth Caritas (Philadelphia):
Challenge: Leading dispersed teams.
Leading dispersed teams comes down to discipline and intention. You must anchor in clarity including priorities, roles and what success looks like to ensure that geographic distance doesn’t create confusion. From there, it’s about building connection and leading through outcomes and trust. The biggest shift is communication. You must be consistent and predictable in a way that reinforces direction and leadership. At the end of the day, it’s still all about the team. They must feel seen, connected, and aligned to the mission, and that creates a successful outcome no matter where they sit.”
It’s all about clarity. High-performing dispersed teams don’t need to be in the same room, but they do need shared clarity. Clear priorities, defined decision rights, and a common understanding of success.
We build intentional connection. You must design connection when managing virtually. It doesn’t just happen by the watercooler like it would in an in-person environment. We create regular touchpoints, consistent visibility, and purposeful in-person moments when they matter most.
It starts with a foundation of trust. Dispersed teams require a shift from managing presence to managing impact. We set clear expectations, give our teams autonomy, and hold them accountable for shared results.
There’s no such thing as over-communicating. In virtual environments, a lack of communication creates confusion. We set a predictable cascade of communication including our priorities, why they matter, and how we are progressing towards those goals.
Don’t lose the human connection. Especially in healthcare, where the work is mission-driven, leaders need to stay “close” to their people. We listen intentionally, recognize contributions, and make sure individuals feel seen for their work.
Meredith Duncan. President and CEO of Texicare (Austin, Texas): In markets where small businesses historically haven’t had options built for them, a new name doesn’t automatically mean a new option people will act on. What we’ve learned is that trust comes from showing up in communities consistently, in ways that showcase we care about the health and wellness of employees everywhere. Our number one goal is to deepen relationships with Texans, because they deserve a health care partner that’s as invested in their communities as they are.
Jennifer St. Thomas. Senior Vice President of Commercial and Medicare Markets for Mass General Brigham Health Plan (Somerville, Mass.): We are focused on the industrywide challenge of affordability, especially in a difficult economic environment for many employers and consumers. Our goal is to provide both short- and long-term support by ensuring our products remain competitive and deliver real value — while continuing to prioritize our members’ individual health needs. This means making thoughtful decisions around benefits design, care coordination, and provider partnerships that help promote sustainability and quality support. By staying member‑focused, we are prioritizing access to high‑quality and affordable care for the communities we serve.
Ty Wang. Co-Founder and CEO of Angle Health (San Francisco): One of the main challenges we continue to navigate are the misconceptions that small businesses and their brokers have regarding self- and level-funding. Today, there are high-quality alternatives to the traditional funding models that give small businesses greater control of their costs and ownership of their data, while still feeling familiar and seamless to administer. The main barrier to adoption is lack of awareness and education.
Martina Lee Strickland. Head of Marketing, PR and Brand for Clever Care Health Plan (Huntington Beach, Calif.): The CMS 2027 Medicare Advantage and Part D Final Rule is one of the more comprehensive ones that we’ve seen, and the geographic variation means the picture looks different county by county. We’re currently doing the work to understand what that means for our members across Southern California. Ultimately, what matters to us most is that our focus remains the same: staying close to our members, ensuring they have access to the providers and care they need to stay healthy, improving health outcomes and delivering an excellent experience so members stay engaged in their care.
Chris O’Donnell. Vice President of Provider Network Innovation and Strategy for Lifetime Healthcare Cos. (Rochester, N.Y.): The Lifetime Health Care Companies take pride in having approximately 70% of our membership being cared for under a value-based care arrangement. While our VBC arrangements have driven improved clinical and quality outcomes, we continue to innovate ways to improve affordability. Aligning incentives that improve/maintain our clinical and quality performance while reducing overall healthcare costs continues to be a challenge.
At the Becker's 5th Annual Fall Payer Issues Roundtable, taking place November 2–3 in Chicago, payer executives and healthcare leaders will come together to discuss value-based care, regulatory changes, cost management strategies and innovations shaping the future of payer-provider collaboration. Apply for complimentary registration now.
