Healthcare affordability remains one of the defining challenges facing our industry. Insurance premiums continue to rise, employers shift more costs to employees, and consumers struggle to navigate a fragmented system characterized by complex benefits, a disconnected experience, and rapidly increasing medical and pharmacy costs.
At the same time, the pace of innovation, new treatments, personalized medicine, virtual care, alternative care settings, and value-based arrangements are increasing opportunities to improve outcomes, but they are also significantly complicating the healthcare ecosystem. Historically, health plans have acted as aggregators, building extensive provider networks, packaging benefits, negotiating discounts, and managing claims. This model was designed for a world where scale, volume, and open access are values.
That world no longer exists.
That’s why the future of affordability lies in health plans that can evolve from passive aggregators to active orchestrators.
Why reluctant payers can’t drive affordability
Today, reducing costs requires more than simply consolidating providers, products, and services. Accelerated premiums, rising costs for GLP-1, gene therapy, and other pharmaceuticals, increased employer interest in alternative health plans (AHPs), and the “affordability cliff” are forcing payers to demand more. Successful health plans require a change in mindset and operating model.
Health plans as new affordable orchestrators
Health plans will always play an important role in providing access to care to large populations. However, the complexity of healthcare in today’s environment requires a plan to align a much broader ecosystem of stakeholders and benefits, payment models, clinical innovation, and member experiences.
Moving from an aggregator to an orchestrator does not mean abandoning the fundamentals of the traditional health planning model. Health plans still require strong networks, competitive products, and effective member engagement. What changes is how these elements fit together. Rather than operating independently, these companies must work together to create a more connected, personalized, and cost-effective healthcare experience.
Orchestration happens across systems, stakeholders, and channels, and it needs to happen at scale. Traditional management systems are designed to handle transactions and do not allow for dynamic adjustments across clinical, financial, and member engagement workflows. For health plans to become true orchestrators of affordability, they need flexible, insight-driven operating models that can respond to members’ changing needs and clinical innovations and support more personalized decision-making based on data, risk profiles, and cost patterns.
Broadly speaking, this transformation requires health plans to rethink three key areas:
- network strategy: Traditional network strategies mainly focused on scale and discounts. In the coordinated model, plans combine value-based reimbursement, innovative provider partnerships, site-of-care optimization, and targeted clinical programs to create a network designed around both outcomes and affordability.
- Product packaging: As aggregators, payers have implemented traditional benefit designs that focus on utilization management and cost sharing. Going forward, health plans will need to package “new networks.” This will be facilitated through progressively thoughtful payment models designed to provide more comprehensive care, built on inventive network designs, bundled with increasingly personalized clinical innovations, and managing the delicate balance of risk and provider relationships.
- experience: The orchestrator actively guides members through the medical journey, rather than reacting to questions after disruption has occurred. This means simplifying benefits, reducing friction, improving navigation, and helping members understand the right care options based on their individual needs.
Orchestrating health care plans: The role of artificial intelligence (AI)
Undoubtedly, artificial intelligence can play an important role in enabling flexible, insight-driven orchestration across the healthcare workforce at scale, but AI is not a panacea.
The greatest value comes from applying AI to targeted use cases where speed, personalization, and scale are most important. For example, AI can support clinical validation, automate aspects of pre-authorization, identify friction points for members, and surface real-time insights that help care advocates provide more personalized support.
AI can also improve health navigation by helping plans understand member sentiment, predict next-best actions, and guide consumers through the complexities of benefits, networks, and clinical programs. Rather than providing general recommendations, AI can help tailor outreach and engagement based on an individual’s health, preferences, usage, and behavioral potential.
Healthcare planning orchestration: What’s next?
The most advanced health plans understand that the future of health care lies in managing the delivery of care, not just funding it. Many have already become orchestrators and are implementing initiatives such as:
- Advanced pharmacy strategy: Plans negotiate for results, bypass PBMs with biosimilar and site-neutral payment models, and integrate with customer savings options such as coupons and rewards programs.
- Health navigation: Health plans are focusing on strong networks, directing members to high-value care sites such as retail clinics and Virtual First. We also proactively increase member engagement through gamification and guided, personalized, action-oriented navigation.
Winning health plans of the future will be those that integrate networks, products, experiences, and clinical innovation into a seamless system that delivers better outcomes at lower costs.
