Visionary Voices
The False Choice Between Profit and Patient Care
The New Reality for Payers
A New Payer Mindset
Instead of investing in member care and operational excellence, payers often default to cutting benefits or raising premiums when facing financial pressure. Zach advocates for a fundamentally different approach; one that focuses on better member outcomes as the pathway to sustainable profitability. Healthcare payers need to move from viewing members as cost centers to understanding them as the foundation of long-term business success.
This shift requires payers to develop deep insights into member populations—not just demographic data, but understanding the specific health challenges, social determinants, and care patterns that drive outcomes within different cohorts. “They need to intimately understand their members in terms of cohorts,” Zach adds.
This is especially important now; the Medicare Advantage landscape is experiencing significant disruption, with major National payers closing or eroding plans within markets. Medicare is changing how it pays health plans, with new rules like V28 that alter reimbursement rates and reshape financial risk.
This market volatility creates both challenges and opportunities. Payers that can demonstrate sustainable member outcomes and operational excellence will be better positioned to navigate regulatory changes and maintain market presence.
AI’s Careful Promise
AI is clearly affecting health care. The key, according to Zack, is approaching AI as a tool for enhancing member care and operational efficiency, not as a replacement for human judgment in healthcare decisions.
Successful AI implementation in Medicare and Medicaid requires balancing innovation with the regulatory and ethical requirements unique to healthcare.
Zach suggests starting with “no-regrets” AI use cases that show clear value and low risk—claims triage, prior-auth summarization, agent assist, fraud/waste/abuse detection, CAHPS/HOS voice-of-member insights, and care-gap prioritization—each tied to measurable outcomes like Stars lift, faster turnaround, fewer grievances, shorter handle time, and narrowed equity gaps. “Enable the workforce by co-designing tools, training teams on when to trust or challenge AI, and establishing roles such as AI product owner and model-risk manager. Put real governance in place: a cross-functional committee to approve models, monitor drift, test bias, manage vendors, and publish transparent model cards,” Zach explains.
A pragmatic path is simple according to Zach: set guardrails and select pilots in the first 90 days, run shadow-mode evaluations at 3–6 months, and scale winners into EHR/CRM workflows by 12 months. Above all, earn trust—disclose when AI assists, offer plain-language explanations, guarantee easy access to a human, and track what matters: clinical outcomes, safety events, member experience, timeliness, productivity, and equity by segment.
Looking Ahead: Three Priorities for Medicare & Medicaid Leaders
1
Develop Member-Centric Financial Models: Build business cases that demonstrate how member outcome improvements drive sustainable profitability rather than defaulting to benefit cuts.
2
Master Cohort-Based Care Management: Develop deep understanding of member populations by region, condition, and social determinants to enable targeted interventions.
3
Build Regulatory Resilience: Establish a repeatable policy-to-operations engine that quickly converts federal and state rule changes into timely updates across benefits, pricing, utilization management, provider contracts, and care workflows—preserving quality, access, and compliance.
The Bottom Line
Organizations that invest in understanding their members deeply, delivering quality care consistently, and building operational excellence will not only survive regulatory turbulence but thrive in it.
If you’re leading a Medicare or Medicaid organization and need partners who understand both the regulatory complexity and the member-care imperative—let’s talk.
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Visionary Voices