PEOPLE SOLUTIONS

Healthcare affordability has become a major focus for policymakers

Healthcare organizations are facing increased oversight, scrutiny, and transparency requirements as federal and state governments pursue a range of strategies intended to lower costs and increase accountability across the healthcare system.

While previous policy efforts often emphasized expanding access through government programs, subsidies, and coverage, current efforts place greater emphasis on transparency, competition, financial incentives, and fraud, waste, and abuse.

Key areas include:

Transparency & disclosure

Policymakers continue to pursue greater visibility into healthcare prices, ownership, and financial relationships. Efforts to expand plan sponsors’ access to claims and PBM data could give healthcare organizations greater insight into spending within their own employee health plans.

Competition & pharmacy economics

PBM practices, prescription drug pricing, vertical integration, and healthcare consolidation are receiving increased scrutiny. DOJ activity around healthcare competition and federal drug-pricing initiatives reflects broader efforts to change market incentives and put downward pressure on costs.

Fraud, waste, & abuse

Program integrity has become a significant focus across Medicare, Medicaid, and the ACA marketplace as the federal government seeks to reduce improper spending and increase accountability, potentially leading to unintended downstream effects for healthcare organizations.

Payment & financing

CMS reimbursement activity, Medicaid financing changes, and developments involving the 340B program can directly affect healthcare organizations’ revenue, pharmacy strategies, and financial planning.

Surprise billing

The No Surprises Act continues to protect patients from certain unexpected charges, while providers and health plans navigate administrative complexity and challenges, such as cost impacts, surrounding the independent dispute resolution process.

Whether these approaches will meaningfully slow healthcare cost growth remains an open question. Reducing spending or changing financial incentives in one area can shift cost, responsibility, or risk elsewhere. Healthcare organizations are particularly exposed to that dynamic because they participate in the system in multiple ways. A reimbursement or 340B change can affect revenue and care delivery operations, while changes involving PBMs, plan transparency, or pharmacy costs can simultaneously affect the organization as an employer and plan sponsor. Similarly, greater access to healthcare pricing and claims data creates an opportunity for healthcare organizations to better understand their own plan spending, but information alone does not produce savings. Organizations need the capabilities and strategy to turn greater transparency into useful action, such as strengthening domestic strategies, evaluating specialty pharmacy approaches, or reassessing total rewards investments.

Build enterprise capacity to respond to evolving healthcare policy

Healthcare organizations cannot react to every proposal, but they can evaluate and plan for which developments create meaningful financial, operational, or workforce implications. Benefits, finance, legal, government relations, and operational leaders should understand where policy changes could create exposure, recognizing that changes in one area can shift risk and cost to another. An enterprise-wide view helps leaders understand important tradeoffs, identify priorities and build flexibility into financial and workforce strategies while avoiding unintended consequences. Organizations have an opportunity to engage before policies are finalized. Understanding legislative and regulatory proposals early and communicating their potential consequences to lawmakers can help healthcare leaders participate effectively in the policymaking process. Leveraging clinicians to meet with lawmakers can be very effective in getting the message across, especially where a negative impact to patient care may result. The policy environment will continue to evolve. For healthcare organizations, the priority is not predicting every change but building the capacity to respond deliberately as those changes affect both their business and their workforce.