As healthcare costs rise faster than reimbursement rates, insurers like UnitedHealth and Molina are grappling with shrinking margins—and the ripple effects are being felt across the care continuum. From rising drug prices and expensive therapies to increased patient utilization and workforce shortages, these challenges are straining traditional payer-provider dynamics and threatening the affordability and accessibility of care.
Recent financial disclosures illustrate the urgency of transformation. UnitedHealth, for instance, cut its profit outlook amid unexpectedly high medical claims costs, triggering sharp stock declines and signaling that traditional models may no longer suffice. As margins compress, the imperative to rethink payer-provider relationships has never been stronger.
To understand how healthcare leaders can preserve access and affordability in this evolving landscape, we turned to members of the Senior Executive Healthcare Think Tank—a curated group of experts in patient experience, policy, digital health, equity and workforce transformation. Their insights reveal not only how payer-provider relationships are changing, but also what strategies healthcare organizations must adopt now to ensure care delivery remains equitable, efficient and financially sustainable.
“Integrated AI isn’t just a tool for efficiency; it’s the foundation for a smarter, more affordable and more patient-centered healthcare system.”
A Fragmented AI Landscape Is Hindering Affordability
As health plans face increasing cost pressures, technology is often seen as the path to relief—but only when it’s used strategically. Eugene Zabolotsky, CEO of Health Helper, cautions that many healthcare organizations are deploying AI in isolated use cases, which can actually worsen system inefficiencies. “Models are being built for diagnostics, operations and patient engagement in isolation,” he says. “Without a connected framework, these tools risk adding complexity instead of value.”
Zabolotsky argues that the solution is integration—connecting payers, providers and patient-facing platforms so insights can flow seamlessly. “Integrated AI isn’t just a tool for efficiency,” he adds. “It’s the foundation for a smarter, more affordable and more patient-centered healthcare system.” That integration, he explains, depends on strong governance, infrastructure to support data security and accessibility, and teams who understand both clinical and technical contexts.
“Insurers that are investing in programs to address SDOH are finding solutions to preserve access and proactively provide care.”
Tackling Social Determinants of Health to Protect Margins
For Mark Francis, Chief Product Officer at Electronic Caregiver, addressing healthcare affordability starts far upstream—as everything from food insecurity, to distance to providers, to child care can substantially increase healthcare costs. “Proactively addressing these issues means focusing on social determinants of health (SDOH),” Francis says. “Insurers that are investing in programs to address SDOH are finding solutions to preserve access and proactively provide care.”
Francis points to partnerships with Uber Health or local agencies as examples of how insurers are responding to these non-clinical needs. At the same time, he sees a growing role for virtual care in closing access gaps—especially in rural communities or for patients who don’t speak English as a first language. “Remote care and telecare are very affordable options to augment in-person care,” he notes.
With this growing trend toward home-based care models to manage chronic conditions and reduce expensive hospital stays, Francis believes that to sustain access, payers must double down on prevention and flexibility—even if that means rethinking traditional models of care delivery.
“Commercial insurances need to adapt strategies to increase efficiency and reduce burden on providers.”
Prior Authorization and Fee Pressures Strain Provider Relationships
While insurers seek to contain costs, providers are increasingly feeling the strain—particularly from fee schedules and administrative hurdles. Fereste Naseh, Founder and CEO of MeTime Healing LLC, notes a growing rift caused by prior authorizations. “Some providers have dropped UnitedHealthcare due to the rise of prior authorizations for procedures that didn’t require them a year or two ago,” she says.
This trend is contributing to provider burnout and, in some cases, shrinking networks. According to the American Medical Association, over 90% of doctors say prior authorizations negatively affect patient outcomes, and the administrative burden often delays necessary care. Naseh warns that unless insurers rethink these systems, payer-provider partnerships will continue to erode.
She believes collaboration is key to restoring trust. “Commercial insurances need to adapt strategies to increase efficiency and reduce burden on providers,” Naseh says. Without change, rising administrative complexity could become its own cost driver—one that undermines both care and payer sustainability.
Key Points for Healthcare Stakeholders
- Integrated AI systems are foundational, not optional. Unified models spanning payers, providers and patients drive smarter care.
- Invest in SDOH and preventive care for long-term cost leverage. Upfront community investment can reduce costly downstream events.
- Streamline prior authorization and provider burden. Reducing administrative drag preserves network and trust.
The Future of Partnerships Under Pressure
Rising care costs and expensive specialty therapies are squeezing insurer margins—and that financial stress will reshape payer-provider dynamics. But this pressure also presents an inflection point: Those organizations that seize alignment, trust, innovation and governance will emerge stronger.
According to insights from Think Tank experts, the path forward prioritizes collaboration, equity and shared risk. Healthcare leaders must act now to architect partnerships built for this new financial reality—so access and affordability endure for patients.
