By Lauren Barca, MHA, RN, VP of Quality, 86Borders
LinkedIn: Lauren Barca
LinkedIn: 86Borders
The headlines for 2025 Medicare, Medicaid, and dual-eligible programs are rife with concerns about proposed changes. While those worries were certainly a topic of discussion at AHIP’s recent Medicare, Medicaid, Duals, and Commercial Markets Forum in Baltimore, Maryland, they weren’t the only story.
With over 800 health plan attendees and 100 speakers, the forum spotlighted innovative approaches aimed at:
- Enhancing member experiences
- Expanding data sharing
- Reducing administrative burdens
Amid the challenges, conversations about partnerships, simplification, and empathy took the lead. Here are my key takeaways from five standout sessions at the event.
Regulatory and Policy Direction: CMS Expectations Are Evolving
Brian Miller, MD, MBA, MPH, FACPM, Associate Professor of Medicine and Business at Johns Hopkins University and a Nonresident Fellow at the American Enterprise Institute, joined John Brooks, Deputy Administrator and Chief Policy and Regulatory Officer for CMS, to deliver the forum’s opening keynote. They provided insights into the evolving regulatory and policy landscape.
Brooks outlined the administration’s top four priorities:
- Enhancing Medicare Advantage (MA) quality, transparency, and patient education
- Modernizing Part D and addressing challenges in standalone prescription drug plans
- Supporting states through the Medicaid redetermination transition
- Enforcing hospital transparency and reducing surprise billing
- Adjusting the Star Ratings system to align with regulatory changes, particularly regarding risk adjustment and equity
Miller emphasized the need for improved care delivery and network design within special needs plans (SNPs), noting that categories like chronic condition SNPs (C-CSNPs), institutional SNPs (I-SNPs), and dual-eligible SNPs (D-SNPs) often provide the most value for U.S. health plans. Where offered, these service lines should remain a priority.
Value-Based Care: Trust and Simplicity with Providers
Provider relationships remain a stubborn headache for health plans, with administrative overload and provider frustration often stealing the spotlight. As value-based care (VBC) programs mature, these challenges are only magnified. In this session, three health plan executives shared their perspectives on how to break the cycle and build stronger provider partnerships.
Pat Geraghty, President and CEO of Florida Blue, called for a shift from transactional, checkbox interactions to genuine collaborations. According to Geraghty, fostering real partnerships with providers aligned on shared VBC goals is the only path forward.
J.P. Holland, MBA, President and CEO of Johns Hopkins Health Plans, emphasized that meaningful data sharing is the bridge to better care. For data to drive real change, it needs to be actionable, timely, and used to close care gaps in tandem with providers.
John Kao, Founder and CEO of Alignment Health, advocated for a bold approach: investing more in high-risk populations. Rather than scaling back on these costly members, Kao argued that targeted, intentional investments can yield both better health outcomes and financial returns.
The common refrain? Trust and simplicity. Providers are drowning in paperwork, and any shift toward value-based care should reduce—not increase—their burden. Supporting providers means making VBC a practical, collaborative effort, not just another layer of complexity.
Takeaways from the Primary Care Study: Lessons for Health Plan Executives
Humana shared insights from its Strengthening Primary Care study, which explored the impact of full-risk primary care. The findings offer two clear lessons for health plan leaders:
- Senior-Focused, Full-Risk Models Work: These models consistently deliver better health outcomes and reduce care disparities.
- Providers Need Support, Not Isolation: Lifestyle interventions and chronic disease prevention are tough for providers to manage solo. Effective wraparound support is essential.
The central takeaway echoes the panel session above. Simplify the system. Providers are bogged down by excessive audits and cumbersome prior authorizations. Moving forward, health plans should prioritize enabling care — not obstructing it.
AI Augments, It Doesn’t Replace the Human Touch
Generative AI took center stage at the AHIP Forum, with Florida Blue showcasing its internal ChatGPT tool. By training it on proprietary data, they’ve reduced hallucinations and improved voice-to-text capabilities for physicians. Additional AI use cases for member support were also explored.
While many agreed that health plans need disruptive innovation, the consensus was clear: changes must be incremental, balanced, and carefully integrated. As Pat Geraghty put it, “In two years, it may be malpractice not to use AI.”
A recurring theme? Empathy. Speakers emphasized that AI streamlines processes, but it can’t replace genuine human connection. Technology should enhance relationships, not stand in for them. New developments in agentic AI, where technology goes beyond generating content or providing suggestions to enable execute goals with minimal human input, may help ensure empathy remains a core component of all member interactions. All eyes will be on AI’s progress and time will tell if the technology remains boom or bust for health plans.
Looking Ahead to AHIP 2025
Next up is AHIP 2025, the association’s flagship event, taking place from June 16–18, 2025, at the Wynn Las Vegas. I’m eager to hear the latest administrative updates and continue the conversation on how health plans can simplify operations, build stronger provider relationships, and maintain the human touch with members.
For real progress, member needs must be understood in their full context — culturally, socially, and emotionally. Only then can our industry truly advance and improve.