Health plans now operate in a far more complex environment than in past years. With economic uncertainty, shifting market forces, and regulatory changes, there is increasing pressure for health plans to do more than just maintain performance; they must deliver real, measurable value.
To succeed in managing the Total Cost of Care (TCOC), health plans must move beyond complex legacy systems and adopt modern technology that unifies data across teams, generates actionable insights, and establishes a shared data language among all stakeholders. This approach depends on thoughtful investments in time, technology, and talent so that they can identify the highest‑impact opportunities and act on them with speed and precision.
In this blog, MedInsight Chief Market Strategist and General Manager of Payer Solutions, Marcos Dachary, explores what these trends mean for payers and how analytics and innovation can help health plans not only adapt, but thrive, in a highly competitive marketplace.
Key questions we will address:
1. What are the main challenges payers face today in effectively managing TCOC?
When it comes to managing the TCOC, payers are juggling a variety of factors that make the job more challenging. First, let us consider the current environment: Inflation, the growing prevalence of chronic disease, and the increasing use of high-cost therapies like GLP-1 drugs are all driving up expenses.[1] As a result, payers are under growing pressure to rein in costs, increase efficiency, and deliver better health outcomes.
In the Medicare Advantage market, enrollment remains highly concentrated, with two carriers serving nearly half of all beneficiaries nationwide.[2] Yet, even the dominant players are grappling with escalating care costs and evolving reimbursement policies that impact profitability. Most recently, major carriers have announced they are scaling back their coverage areas for 2026, cutting the number of states and counties they serve.[3] These shifting dynamics may open up new opportunities for smaller, regionally focused plans to expand their footprint in this competitive space.
Meanwhile, Medicaid is facing its own set of challenges. Currently, 76.8 million people are enrolled in Medicaid and CHIP nationwide. This is a 19% decrease from the total enrollment in March 2023, but still 7% higher than enrollment levels in February 2020, before the pandemic.[4] Furthermore, the passage of H.R. 1 (also known as the “One Big Beautiful Bill Act”) in July 2025 introduces new administrative requirements and eligibility conditions, such as work requirements, for individuals applying for or maintaining Medicaid coverage. It also limits states’ ability to use provider taxes to fund their Medicaid programs.
2. In what ways can health plan leaders and teams leverage an enterprise healthcare analytics system to their advantage?
An enterprise analytics approach helps to unify data access and analytics capabilities across the entire health plan, ensuring that every stakeholder (from senior leadership to frontline teams) has the timely, relevant information needed to make informed decisions and drive meaningful improvements.
For example, financial leaders can leverage the platform for accurate forecasting, cost control, and revenue optimization, which are critical to maintaining financial health. Data officers can also use the same platform to dig into cost drivers and anticipate future trends, helping the organization stay proactive rather than reactive.
Medical economics and actuarial teams can leverage the same system to gain a comprehensive view of spending across the full patient journey, enabling more informed and strategic decision-making. By integrating medical, pharmacy, and utilization data, teams can identify cost drivers, uncover unwarranted variation in care, and evaluate the true financial impact of clinical programs and payment models. These insights support value-based care initiatives, guide benefit and network design, and help prioritize interventions that improve outcomes while controlling costs.
From an operational perspective, analysts in all areas of an organization can benefit greatly from a shared platform that enables rapid, in-depth data exploration without the usual delays. This approach empowers them to answer complex questions efficiently and without expending additional time and resources to ensure the data is accurate and consistent across teams. Additionally, sales and customer service teams can use these insights to better address employer concerns about healthcare spending, enhancing client relationships and trust.
Finally, transparency with provider partners is essential. By sharing actionable data, organizations can give providers the clarity they need to understand performance and opportunities for improvement. Aligning incentives further strengthens this collaboration and encourages meaningful change.
3. How does the Milliman MedInsight Payer Platform enhance health plans’ analytics capabilities to address the TCOC?
The Milliman® MedInsight Payer Platform is designed to be the “go-to” analytics platform for health plans looking to proactively manage TCOC and other key use cases, like employer group reporting, provider network analysis, and population health.
First, we make the data integration process simple and seamless. At Milliman MedInsight (MedInsight), we take in an organization’s claims, eligibility, pharmacy, and clinical data exactly as it is. With decades of experience, we clean and structure that data into a unified, highly usable format, creating a common “performance language” that eliminates confusion over definitions and metrics.
Next, MedInsight advanced analytics goes beyond foundational reporting to deliver deeper, more actionable insights. By uncovering patterns in avoidable ER visits, clinical variation, pharmacy adherence, and other key performance drivers, it helps organizations move from simply viewing data to actively improving outcomes. Our proprietary groupers, like the Milliman Advanced Risk Adjusters (MARA) and its rising risk module, focus on the clinical drivers of member cost at the site of care where meaningful change is possible. This approach helps plans identify high-cost drivers and gaps in care, empowering their teams to target interventions and achieve measurable savings.
We also layer in Milliman’s exclusive industry benchmarks, so payers can review their outcomes and performance at various percentiles across similar populations. Our continuously updated dashboards make it easy to spot when performance is off track and to keep improvement opportunities front and center.
Finally, all of this is delivered through an intuitive, user-friendly interface that supports everyone from medical economics and clinical quality leaders to analysts and actuaries. Users can easily explore the data, drill down for root causes, and quickly find the answers they need. This enables faster, more informed decision-making across the organization.
With these capabilities, the Payer Platform becomes an essential enterprise solution, helping health plans drive measurable improvements in cost, quality, and overall organizational performance year after year.
4. What sets MedInsight apart from other health data platforms currently available?
MedInsight is unique in the health data analytics market for several reasons. First, we have a long history of working closely with both payers and providers. Since the late 1990s, our team has built a robust suite of analytics tools that act as a “virtual nerve center” for health plans. This enables organizations to monitor performance, act quickly, and stay competitive. We are also honored that MedInsight was recognized as Best in KLAS for Data Analytics (Payer) in 2025. One of our biggest differentiators is our exclusive use of Milliman risk- and population-adjusted benchmarks. These benchmarks allow health plans to identify highly specific opportunities for improving TCOC at a detailed level, something finance and medical economics teams especially appreciate.
As shown in the graphic below, “loosely managed” populations are those with minimal or ineffective healthcare management practices. These groups rely less on evidence-based guidelines, have limited cost-control incentives, and often experience higher use of unnecessary or expensive services—leading to increased costs and less efficient care delivery.
In contrast, “well-managed” populations benefit from strong healthcare management. Evidence-based practices are consistently applied, cost and quality incentives are aligned, and unnecessary or high-cost services are reduced. The result is lower overall costs, better outcomes, and more efficient use of healthcare resources. The graphic below illustrates the progression of an organization from a loosely managed state to a well-managed one, highlighting key improvements in data integration, process automation, and analytics capabilities at each stage to better manage costs and outcomes.
Whether you’re a large national health plan, a regional plan, or a payvider, MedInsight prepares you with the insights needed to manage risk effectively and achieve better outcomes. In fact, our renewal rate is over 95%, showing that organizations consistently find ongoing value in our solutions.
5. Where can I find more information about the MedInsight Payer Platform?
Schedule a call: Connect with one of our healthcare analytics experts.
Download the eBook: Find out how an enterprise analytics approach can accelerate data insights.
Watch the webinar: Join webinar our upcoming webinar to take a deep dive TCOC management and discover how CareFirst BlueCross BlueShield leverages data, innovative partnerships, and proven strategies to achieve meaningful value-based care goals and improve outcomes for their members.
References:
1. 2025 Milliman Medical Index
2. Medicare Advantage in 2024: Enrollment Update and Key Trends | KFF
3. UnitedHealthcare, Humana, Aetna scale back Medicare Advantage plans for 2026 | Healthcare Dive
4. Medicaid Enrollment and Unwinding Tracker | KFF
