Top 10 Takeaways from the HealthEdge® Annual Payer Market Planning Report 2025
As we approach 2025, health plan executives are facing new challenges and opportunities. The HealthEdge® Annual Payer Market Planning Report 2025 outlines the top priorities, investments, and strategies health plans are adopting to remain competitive and compliant in today’s healthcare environment.
Based on insights from over 450 health plan leaders, the report sheds light on key trends and emerging areas of focus for the coming year. Don’t have time to read the full report? No worries! Here are the top 10 takeaways health plan leaders need to know as they gear up for the year ahead:
1. Security and Data Protection are Top Priorities:
Data security has become the top technology priority for 46% of health plan leaders due to recent high-profile cyberattacks in the healthcare sector. Keeping patient information secure while maintaining privacy compliance is a must. Additionally, 26% are prioritizing technology modernization to streamline operations and enhance member experiences.
2. Technology Modernization Will Drive Efficiency:
In response to rising costs and complex regulatory requirements, health plans are turning to technology modernization. Leaders are investing in digital health platforms, member experience tools, and automated processes to reduce operational costs and improve outcomes.
3. Artificial Intelligence (AI) is Going Mainstream:
AI continues to gain traction, with 15% of health plan leaders piloting enterprise AI use cases. From automating care management to improving claims adjudication, AI is viewed as a game-changer tool for enhancing efficiencies and reducing administrative burdens.
4. Cost Management Remains a Major Challenge:
Unsurprisingly, cost management tops the list of concerns, with 54% of respondents indicating it as their primary challenge. Health plans are under pressure to reduce operational expenses while delivering high-quality care to members. Retaining a skilled workforce (44%) and growing in a competitive market (36%) are also critical issues executives are grappling with.
5. Regulatory Compliance is a Pain Point:
Navigating complex healthcare regulations remains a top concern, with managing fee schedules and staying compliant with CMS rules cited as key challenges. Only one-third of respondents feel prepared for upcoming regulatory requirements such as Transparency in Coverage, the No Surprises Act, and Payer-to-Payer Data Exchange associated with the Interoperability and Electronic Prior Authorization Act. Automated enrollment, compliance monitoring, and claims auto-adjudication are key investment areas to address regulatory challenges.
6. Enhancing Existing Products and Services is the Path to Growth:
When evaluating business growth, health plans prioritize enhancing existing products or services (62%), likely with a focus on integrations and interoperability. To expand and compete effectively, health plan execu executives tivees are investing in AI, care management workflow solutions, and payment integrity tools such as HealthEdge Source
. provider network management (33%), payment integrity (22%), and value-based care contracting (19%) to build stronger relationships with providers. Common challenges prioritize es in provider engagement include delays in claims processing, limited access to real-time data, and lack of transparency, all of which health plans must address through integrated solutions.
7. Telehealth and Remote Care are Expanding:
While telehealth surged during the pandemic, health plans continue to invest in telehealth services to expand access to care, especially in mental and behavioral health. Remote patient monitoring (RPM) is another key focus, with 63% of respondents planning to invest in this area to enhance chronic disease management and reduce hospital admissions.
8. Health Plans Are Investing in End-to-End Managed Care Solutions:
To streamline workflows and improve operational efficiency, health plans are increasingly looking for end-to-end care management solutions. These solutions enable the integration of clinical, administrative, and financial data, allowing better care coordination, cost management, and member engagement. Solutions like HealthEdge’s HealthRules® Payer and GuidingCare® are designed to meet these needs by integrating claims, care management, and member engagement in a single platform, reducing friction and improving outcomes.
9. Improving Member Experience is Crucial:
Health plans recognize that delivering a superior member experience is vital for both retention and satisfaction. To achieve this, they are investing in member portals, self-service tools, and mobile apps, such as the solution, that allow members to access care information and manage their health more easily. Addressing challenges such as high out-of-pocket costs and claims denials is essential to improving the member experience and driving engagement.
10. Telehealth and Remote Care are Expanding:
While telehealth surged during the pandemic, health plans continue to invest in telehealth services to expand access to care, especially in mental and behavioral health. Remote patient monitoring (RPM) is another key focus, with 63% of respondents planning to invest in this area to enhance chronic disease management and reduce hospital admissions.
As health plans head into 2025, they face a complex landscape marked by regulatory changes, rising costs, and heightened member expectations. By focusing on security, technology modernization, AI, and improving both provider and member engagement, health plans can position themselves to navigate the challenges ahead and seize new opportunities for growth. These investments will not only enhance operational efficiency, but also ensure that health plans are prepared for the evolving demands of the healthcare industry.
Download the full report to learn how over 450 health plan leaders are preparing for 2025.
