What health plan leaders should know

1. Regulatory changes with the new administration

The new administration is exploring potentially significant shifts in healthcare policy. We are watching several potential changes, including:

• Proposals to make Medicare Advantage the default Medicare enrollment option which would create growth opportunities for health plans
• The Centers for Medicare & Medicaid Services (CMS) continued prioritization of transparency, with new rules set to streamline prior authorizations and introduce new API reporting requirements by 2026
• Reforms to the Affordable Care Act (ACA) and Medicaid expansion

2. Rising cybersecurity threats

Cybersecurity remains a critical priority as ransomware attacks in the healthcare sector surged in 2024, with the average breach costing up to $10 million. Beyond financial losses, organizations are seeing increased accountability at the executive level for cybersecurity failures.

Health plans must adopt a proactive approach that includes comprehensive risk assessments, asset inventories and strengthened vendor management practices to mitigate supply chain vulnerabilities. With cyber risks showing no signs of slowing, a robust, forward-looking cybersecurity strategy is essential.

3. The acceleration of value-based care

Value-based care continues to gain momentum with alternative payment models now accounting for 45% of total healthcare spending, a 4% increase from the previous year. As these models expand, health plans must focus on aligning value-based programs goals to provider and member incentives, addressing care gaps and leveraging actionable data to improve health outcomes and control costs. Investments in interoperability, risk capture and personalized member outreach will play an important role in delivering measurable results in value-based programs.