Inflation Reduction Act Scenario: The Inflation Reduction Act (IRA) would be significantly altered,...
The US healthcare industry is undergoing significant change, driven by policy shifts that are reshaping payer strategies, care delivery models, and consumer engagement. Understanding how payers are responding to these challenges and opportunities is crucial for market researchers and other professionals looking to provide effective, informed solutions.
To explore these shifts, we conducted in-depth research with payers and partnered with David Byram, a Senior Partner at EVERSANA with over two decades of expertise in global pricing strategies, health policy analysis, and payer engagement, and Dee Chaudhary, a Principal at Clarivate, who brings over 20 years of expertise in life sciences consulting and biopharma strategy.
Together, we explored several practical scenarios, using targeted questions to uncover the nuances of payer perspectives and their broader impact on the market.
This three-part blog series offers a deep dive into our findings, which are laid out by policy focus, scenario, and question. Inside, we present key takeaways, quotes, and actionable insights to help you navigate the complexities of policy-driven change and provide the tools you need to anticipate market shifts, refine strategies, and provide the tools you need to navigate a rapidly shifting landscape with confidence.
Pricing Transparency
Scenario: All hospitals would be required to disclose service costs, including negotiated discounts.
Any mandated disclosure of hospital service costs, including negotiated discounts, would redefine the competitive dynamics of the healthcare market. While U.S. payers broadly agree on the importance of price transparency, their perceptions of its impact vary:
Question: How important is price transparency to competitive positioning in the market?
There is consensus among payers: Pricing transparency for competitive positioning is a critical factor, with responses weighted to higher importance on the scale, highlighting transparency as a key market differentiator.
The implications of transparency go far beyond compliance. Publicly revealing negotiated discounts threatens proprietary pricing structures that have historically provided competitive advantages, potentially destabilizing payer-provider agreements and eroding market differentiation. For hospitals and manufacturers, this could weaken their ability to sustain pricing models.
Transparency is also likely to attract intense media and regulatory scrutiny, sparking public and congressional discussions around equity and affordability. Organizations perceived as driving high costs or inequities in pricing could face reputational challenges and increased oversight. Meanwhile, empowered consumers, armed with detailed pricing information, may demand more competitive, value-driven options, intensifying competition across the market.
Despite the challenges, transparency can offer payers a unique opportunity to redefine their value propositions. By educating members on how pricing intersects with quality and outcomes, payers can emphasize value-based care models that align cost with quality, promoting trust and differentiation. Moreover, close collaboration with providers will be critical to ensure that transparency efforts maintain network stability and patient access.
“Concerns around anti-competitiveness in healthcare are growing as three major companies dominate the delivery chain, spanning manufacturing, pharmacy, and retail, while Congress and the administration push for initiatives to decouple their integration and restore true market competition.”
David Byram
Senior Partner, Eversana
Takeaway: Transparency may fundamentally reshape payer strategies, provider relationships, and consumer behavior. Publicly disclosed negotiated discounts risk destabilizing payer-provider agreements and exposing competitive vulnerabilities, while increased media and regulatory scrutiny will amplify pressure to address perceived inequities in pricing. At the same time, empowered consumers are expected to actively compare options, driving demand for lower-cost or higher-value providers and intensifying competition across the healthcare ecosystem.
Establishing value beyond cost and understanding how transparency changes market shifts is key.
Telehealth
Scenario: Telehealth services are expanded, building on the momentum from COVID-19, and federal grants strengthen infrastructure.
Any expansion of Telehealth services, with support from federal grants to improve infrastructure, would mark a distinct progression in care delivery models from current standings. There is a consensus among payers that Telehealth could positively influence member access.
Question: What impact would Telehealth service expansion have on your members’ access to care and care delivery?
Service expansion is largely seen as a positive shift, with two-thirds of payers expecting a positive improvement in care delivery and/or access. However, one-third of payers believe this impact will remain unchanged, suggesting barriers such as reimbursement structures or provider adoption may still limit its full potential.
It has proven value as a cost-efficient solution for populations facing barriers to in-person care, such as those in underserved, elderly, and rural communities. Federal grants for infrastructure improvements would aim to tackle connectivity challenges, paving the way for broader adoption and reducing reliance on emergency departments and hospitals. However, financial misalignment remains a significant obstacle, with physicians favoring in-office visits due to higher reimbursement rates. Without addressing these disincentives, widespread Telehealth adoption may remain limited.
There are also further opportunities in preventive care, enabling proactive management of chronic conditions and reducing unnecessary escalations to high-cost care settings. Yet, some payers remain cautious, requiring measurable cost savings and clear outcomes to fully embrace its potential.
“Payers may not view telehealth as beneficial unless they recognize its potential for cost savings in preventive care and management of underserved patients."
Dee Chaudhary
Principal, Clarivate
Takeaway: Telehealth expansion holds transformative potential, particularly for rural and underserved populations, by improving access and reducing care disparities. However, unresolved reimbursement challenges hinder widespread adoption among providers. Additionally, while Telehealth’s preventive care capabilities are promising, payers need evidence of tangible cost savings and improved outcomes to fully commit.
There’s broad agreement that telehealth has the potential to become a key part of preventive care models, offering opportunities to improve cost efficiency and scalability. For researchers, it’s also a chance to explore how this integration can be effectively achieved.
Affordable Care Act and Inflation Reduction Act
Scenario: All Inflation Reduction Act subsidies and the Affordable Care Act are being scaled back with the 2025 expiry.
A rollback of subsidies from the Inflation Reduction Act (IRA) and the Affordable Care Act (ACA) could reshape the cost landscape. The consensus is clear across payers - costs would rise, and financial impacts would be significant
Question: What impact do you foresee a reduction in subsidies from the Inflation Reduction Act and the Affordable Care Act having on costs and cost structures in the next three years?
Scaling back subsidies from the Inflation Reduction Act and the Affordable Care Act is widely expected to drive up healthcare costs, with most respondents anticipating a moderate or major increase.
This shift may drive strategic adjustments, including changes to reimbursement rates, benefit structures, and cost-sharing mechanisms for members. While the extent of these changes may vary, the overall sentiment points to a period of financial recalibration and a sharper focus on cost containment strategies.
End users would also need to prepare for industry-wide ripple effects, including potential premium increases and a tightening of payer budgets to manage the anticipated surge in expenses.
“The scaling back of these subsidies would likely disrupt the current cost structures, leading to a significant increase in healthcare costs across the board.”
Pharmacy Director (covering one million lives),
Regional Managed Care Organization
Takeaway: Payers could face heightened financial uncertainty if subsidies roll back. For most, rising costs will require tighter budget controls, potential premium increases, and innovative cost-containment strategies. Stakeholders would need to prepare for a healthcare environment where affordability challenges deepen, and operational efficiency becomes critical.
Focusing research on payer reimbursement models can inform service and messaging offerings to align with payer priorities.
Explore more payer-related political impact trends in this three-part series:
- Part 2: Inflation Reduction Act, Medicare, FDA and CDC reform, and Drug Importation
- Part 3: Health Savings Accounts, Rural Health, Veteran Care, and Conclusions
Or are you ready to dive deeper into these insights? Book a call with Techspert’s Payer network
