In an era shaped by unpredictable shifts in the healthcare landscape, innovative approaches took center stage at Becker’s Payer Issues Roundtable Spring 2025. For those sessions highlighting data insights through advanced analytics, the necessity of quality data is undeniable. Multiple speakers pointed out that maintaining a competitive advantage depends on proactive planning supported by sophisticated analytics, coupled with a deep understanding of emerging patient needs, to drive sustainable impact. At the event, the Milliman MedInsight team had the opportunity to connect with representatives from national and local healthcare organizations. Our conversations covered emerging trends, shared challenges, and innovative solutions shaping the future of healthcare analytics.
Among the many challenges currently faced by the healthcare industry, it is grappling with the dual challenges of leveraging artificial intelligence (AI) and navigating the uncertainties of rapidly changing policies. For health plan organizations, implementing forward-thinking strategies is crucial to delivering high-quality care and improving operational efficiency. In this article, we will explore the key issues facing payers today, with a focus on navigating uncertainty, AI adoption, and the importance of data quality.
1. Navigating policy changes and rising costs
Payers currently face challenges stemming from shifting regulations, rising healthcare costs, and increasing demand to improve member engagement and decision making. . A key focus of the event was the dynamic discussions surrounding how payers are keeping a close watch on evolving policies, especially those affecting Medicare and Medicaid. Industry leaders highlighted the forward-thinking strategies being developed to support members who might be affected by these evolving regulations. From harnessing advanced analytics to identify vulnerable populations, to implementing targeted outreach and support programs, payers are taking proactive measures to help members navigate these transitions with confidence and maintain continuity of care. For instance, one health plan is exploring ways to offer employment resources to members as a means to help offset the impact of losing Medicaid benefits, demonstrating a commitment to holistic support beyond traditional healthcare coverage.
To ensure financial stability and improve member satisfaction, health plans are finding they must remain a step ahead in the face of these challenges while balancing the need to innovate with caution. The implications of failing to adapt are significant, with potential consequences including decreased member satisfaction, reduced operational efficiency, and increased costs.
2. AI adoption among health plan organizations
AI took center stage in several payer discussions, underscoring its growing importance across multiple operational areas. Payers emphasized the potential of AI to streamline processes, enhance risk assessment, and improve member engagement while reducing costs and supporting better outcomes.
Examples include the use of personalized call centers and chatbots to address common inquiries, allowing human representatives to focus on more complex issues. Additionally, some plans have begun using AI-driven customer sentiment analysis tools to assess customer service calls and gauge members’ overall satisfaction with their experience. However, organizations remain cautious, focusing on specific use cases as their governance frameworks continue to evolve. Meanwhile, the pressure from current macro-level factors—, like rising healthcare costs are increasing the urgency for payers to enhance their digital transformation efforts. This includes integrating AI-enabled tools within their analytics frameworks to rapidly adapt to new market dynamics.
3. The growing importance of data quality and governance
As payers increase their adoption of AI and other advanced technologies, they are placing a stronger emphasis on data quality and governance to support these initiatives. On a foundational level, this means creating robust, integrated data platforms that consolidate and connect disparate information sources, including claims, clinical, and other health data—so that a more holistic, actionable view of member needs can emerge. Achieving such integration requires well-defined governance structures that establish clear data standards, outline accountability roles, and ensure compliance with evolving regulatory requirements. For example, one health plan is leveraging advanced data science to help their healthcare leaders uncover patterns that help tailor services to the unique characteristics of the populations they serve.
High-quality data is also crucial to studying healthcare delivery systems and identifying ways to optimize it. For example, provider network management and development approaches (e.g., value-based contracting or building narrow networks) require high-quality data to make informed decisions and measure performance. The completeness, accuracy, statistical credibility, and applicability of your data sources are critical elements for reliable data analysis. By leveraging reliable data, health plans gain the precision needed to identify cost and utilization patterns, compare their offerings to competitors, and strengthen network design to improve both member access and care affordability. In contrast, the absence of quality data can create blind spots that undermine strategic decision-making and hamper efforts to coordinate services, reduce unnecessary spending, and sustain long-term success in an increasingly data-driven healthcare environment.
4. Creating proactive organizational strategies with Payer Insights
As health plans move forward, they should continue to monitor industry developments, invest in AI and data governance, and prioritize member needs. By doing so, they can build a more sustainable and responsive healthcare ecosystem that is better equipped to meet the challenges of a rapidly changing landscape.
The Milliman® MedInsight Payer Insights application is offered through our Payer Platform—a robust, highly scalable solution designed to handle the complex data demands of today’s health plan organizations. Powered by the MedInsight Health Cloud, Payer Insights offers far more than member-level perspectives—it delivers comprehensive, high-level analyses across total health plan operations. Instead of simply consolidating data, Payer Insights applies advanced analytics and leverages the proven methodologies of our industry-leading groupers to transform complex information into clear, actionable intelligence. Sophisticated analyses run seamlessly in the background, enabling health plans to pinpoint cost-saving opportunities, elevate care quality, and boost operational efficiency. With interactive dashboards and flexible reporting, Payer Insights empowers stakeholders to make informed decisions, drive strategic initiatives, and achieve stronger outcomes for both members and the organization.
Built on the MedInsight Health Cloud, the Payer Insights solution seamlessly aggregates and synthesizes data from multiple sources—including claims, clinical records, pharmacy information, and more—to deliver clear and actionable insights on achievable health plan opportunities. By consolidating these distinct data streams into a centralized system, it provides an up-to-date and complete portrait of your member population, enabling more informed decisions and targeted interventions to identify cost-saving measures, improve care quality, and target areas for operational improvement.
Payer Insights transforms complex data and business challenges into meaningful results that accelerate:
- Speed to insight: Quickly monitor cost drivers, quality of care, and utilization and cost trends over time using intuitive dashboards and reporting views that leverage Milliman thought leadership.
- Access to comprehensive, reliable data: Evaluate and benchmark plan performance against industry standards using a vast, thoroughly vetted data repository, rigorously reviewed through the MedInsight Data Confidence Model.
- Launchpad to MedInsight through purpose-built reports: Effortlessly access reports and dashboards that leverage expert level use cases of the MedInsight Health Cloud, tailored to the vast needs and goals of a health plan payer, with little to no training required.
Payer Insights empowers health plans to adapt rapidly in an ever-evolving healthcare environment, confidently implement new initiatives, and deliver high-quality care and maintain operational efficiency.
Learn how MedInsight can help you navigate payer challenges
Schedule a call: Connect with one of our healthcare analytics experts.
Visit our website: Learn more about our Payer Platform and Payer Insights offering.
Meet our experts: Visit us at the AHIP 2025 conference in Las Vegas this week.
