The healthcare industry needs to have more conversations about patient experience, AI and preventive care, according to payer executives.
Becker’s connected with 25 leaders to learn more about what they say is underdiscussed in healthcare.
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Editor’s note: Responses have been lightly edited for clarity and length.
Question: What is not being talked about enough in healthcare?
David Agler, MD. Chief Medical Officer at First Choice Health: We must shift our focus from simply delivering care to truly understanding the patient’s experience within the healthcare system. This means acknowledging the overwhelming complexity of navigating appointments, insurance, and billing, which often leaves patients feeling lost and frustrated. We need to address the systemic barriers, like long wait times and physician shortages that lead to patient disengagement and reliance on costly emergency care. Ultimately, a patient-centered approach demands transparency in costs, simplified processes and a genuine commitment to easing the burden of accessing necessary medical services. It’s time to prioritize the human element, ensuring that every individual feels supported and empowered throughout their healthcare journey.
Margaret Anderson. Interim President, Senior Vice President and Chief Sales and Marketing Officer at Health Alliance Plan: Patient choice isn’t one size fits all. What matters most to one person may be different for another. That’s why we offer a range of options — PPOs for broad access, HMOs for coordinated care and cost savings, and high-performing networks that provide great value. As we continue to grow statewide, our focus remains on ensuring members have the flexibility to choose the care model that works best for them, with access to high-quality providers when and where they need it.
Stephanie Argentine. Chief People Officer at Centivo: Focusing on the employer sponsored market, there are three issues of concern that I see could use more focus and meaningful solutions, although perhaps not more discussion. No. 1: Affordability. If the average worker has $400 or less in savings and if benefits is a huge portion of the personnel cost structure for business, we need affordable benefit solutions. No. 2: Fiduciary duties in the self-funded commercial space. The recent spate of class action litigation for [Employee Retirement Income Security Act] medical benefit plans —a la the prior focus on fees in 401(k) plans — is of concern for self-funded employers and their consultants. What should we as payers be thinking about? No. 3: The need for greater numbers of primary care providers, primary care provider reimbursements and areas of the country in disproportionate need of greater primary care access.
Jeff Bak. President and CEO of Imagine360: Despite increased health insurance coverage, 41% of Americans still struggle with medical debt, even those with employer-sponsored plans. Traditional employer-sponsored health plans often prioritize convenience over value, leading to higher costs for employees. With a median American salary of $48,000 and an average out-of-pocket cost of around $5,300 for an employer-sponsored health plan, employees are spending more than 10% of their pretax annual salary on healthcare alone in emergencies. This situation leaves many “functionally uninsured,” forcing them to make tough choices like cutting back on essentials or forgoing necessary medical care. We need to consider how can we, as an industry, find solutions to make healthcare affordable for the average American family?
Eric Cannon, PharmD. Chief Pharmacy Benefits Officer at Select Health: There are three things I don’t think we talk about enough:
- There are numerous discussions about transparency in the PBM space. Too many PBMs claim full transparency yet only a few aspects of their operating models are genuinely transparent. When speaking with self-funded employer groups, I consistently hear that some PBMs refuse to provide their claims data because of ‘confidentiality;’ yet, the employer is the one who paid those claims. If data is shared, access to it could be delayed for months, which hardly exemplifies transparency. This begs the question: What is the definition of ‘transparency’ when it comes to PBMs?
- What ultimately drives down the costs of prescription drugs? I would argue it takes four synergistic factors: 100% transparency, solid utilization management, clinical editing and coordination with prescribers. These four factors must be intertwined to manage prescription drug costs effectively.
- Health plans and PBMs control costs through utilization and access, which means they are in the business of saying ‘no’ to certain prescription drugs. Is there a world without ‘no’ that actually drives costs down? I don’t know but I would love to talk about it.
Anita Edwards, MD. Medical Director and Co-Chairman, Health Equity Committee, Medicaid Segment at Highmark Wholecare: We’re not talking enough about the power imbalance in health care that cause patients to lack the knowledge and skills — such as understanding medical terminology, insurance coverage, and their rights — to effectively
navigate the system and manage their care. Providers are failing to empower patients as active participants, neglecting to provide clear explanations and shared decision-making tools. This knowledge gap breeds uncertainty, distrust and, ultimately, health inequities. The result is patients feeling lost and unable to access appropriate, affordable care.
Leigh Efird, PharmD. Director of Pharmacy at Aledade: I am particularly interested in elevating the role of pharmacists in delivering high-quality preventive care, especially for individuals with chronic conditions like high blood pressure, using value-based care models.
Michael Hunn. CEO of CalOptima Health: One thing that you learn as a CEO, after many years in executive leadership, is that it’s never as good as you think and it’s never as bad as you think. However, finding a balanced approach to problems is often left on the proverbial cutting room floor as being too complex. What often gets missed is workforce development. Who is going to take on key roles in the future? How are we going to invest in developing the workforce and tackling talent shortages? Candidly, who is going to be there to take care of us when we have our highest healthcare needs? I recommend robust dialogues and planning for workforce development and investments. Our health plan, here in Orange County, Calif., is investing $50 million locally towards healthcare workforce development including, social workers, nurses, physicians, physician assistants and community based behavioral health professionals. My recommendation: Start talking about it before it’s a burning platform.
Angie Kalousek Ebrahimi. Senior Director, Lifestyle Medicine at Blue Shield of California: In the American healthcare system, payers are largely focused on paying claims for acute and chronic conditions, but we are not placing enough focus on prevention. In addition to screenings and immunizations, prevention can show up as programs that help people lose weight, exercise more, manage stress and nurture their mental health. By focusing more on prevention, we can entirely avoid chronic conditions or catch health issues early when they are easier to treat. In the end, this will not only improve long-term health outcomes but also improve the cost profile of our members.
Ali Khan, MD. Medicare Chief Medical Officer at Aetna, a CVS Health company: Everyday health challenges and social factors like loneliness, making healthy lifestyle choices and living in a suitable environment significantly influence health outcomes and quality of life for older adults. For example, research shows that social isolation or loneliness can impact overall well-being as it increases older adults’ risk for more serious mental and physical health conditions like heart disease, obesity and depression. With more than one third of older adults reporting they feel lonely, it’s evident that there’s a need for clinicians to view social factors as key components in older adults’ overall health and well-being. Unfortunately, loneliness is often an afterthought, and physicians will prioritize longer-term clinical care and treatment plans, resulting in gaps in care. At Aetna, we’re focused on bridging this gap and connecting the dots between clinical care and day-to-day support. We offer our Medicare Advantage members a variety of benefits, including our SilverSneakers fitness benefits, social connectivity services and in-home support. By focusing on total well-being, we’re helping members achieve their best health in all aspects of their lives.
Nancy Klotz, MD. Chief Medical Officer at Brighton Health Plan Solutions: One critical but under-discussed issue in healthcare is the diminishing role of community-based primary care providers in managing patient care comprehensively. Traditionally, PCPs served as the central coordinators, guiding patients to appropriate care, preventing unnecessary emergency room visits and reducing avoidable hospital admissions. However, increasing reliance on fragmented networks, retail clinics, and hospitals has disrupted continuity of care, weakening patient-provider relationships and leading to poorer health outcomes and higher costs for both patients and payers. To address this challenge, innovative care models such as enhanced care management programs and direct contracting — where employers and plan sponsors partner directly with provider organizations, with administrative support from third party administrators — are gaining traction. These approaches aim to improve care coordination, enhance patient outcomes, and control rising healthcare costs by fostering stronger provider-patient relationships and incentivizing high-quality, value-based care.
Mamata Majmundar, MD. Advisor for UK Innovate, former Chief Medical Officer at Evry Health: We need to have more real conversations with members to understand what truly matters to them. While we invest in tools and strategies, are we listening enough to their experiences? Are they struggling with prior authorizations, long hold times, care management barriers, or something else? How can we make their journey easier to increase engagement? By asking the right questions, we can create a more seamless and supportive experience.
Dawn Maroney. President of Alignment Health: The increase in medical over-testing is draining healthcare resources while exposing vulnerable patients — especially seniors and low-income populations — to unnecessary risks, anxiety and financial strain. Too often, excessive tests are driven by financial incentives rather than clinical necessity and at the expense of patient-centered care. To truly prioritize health and equity, we must address this systemic issue and realign our healthcare system to reward appropriate, value-driven care over sheer volume. Alignment Health collaborates with its provider partners to provide the right care at the right time.
Mark Mugiishi, MD. CEO of Hawaii Medical Service Association: The major issues around healthcare across the nation are already being discussed at all levels. The issues include affordability, access to care, health determinants, and emerging issues such as digital transformation, cybersecurity, and how AI will impact the industry, to name a few. As there are increasingly disruptive forces impacting healthcare — for example, federal policy and reimbursements — we see the intense need for prioritization and solutions. Trying to boil the ocean will make things worse, not better. So, it’s a matter of how to focus, prioritize and have a positive impact on what’s most meaningful in your community.
Pleasant Radford Jr. Health Equity Officer at UCare: Climate change significantly impacts health and creates new public health challenges. Rising temperatures lead to longer pollen seasons, worsening allergies and asthma. Additionally, the rising temperatures contribute to frequent and intense heatwaves which cause heatstroke, dehydration, and cardiovascular stress, particularly among older adults and outdoor workers. Lastly, extreme weather events contribute to anxiety, PTSD, depression, and climate-related displacement. The healthcare industry can help combat climate change and improve health by engaging in climate policy advocacy to protect public health, collaborating with local government to address climate-related risks for your residents and training healthcare workers on the health effects of climate change and how to address them.
Aisha Rahim, MD. Medical Director and Co-Lead, AI Governance Council at Johns Hopkins Health Plans: One critical gap in healthcare discussions, especially in AI implementation within health plans, is the lack of direct member involvement. While payers invest heavily in AI-driven predictive analytics, utilization management, and personalized care pathways, the end users — members — are often an afterthought rather than active participants in the process. AI models are only as effective as the real-world engagement they drive, yet health plans rarely incorporate member feedback in model training, algorithm transparency or trust-building initiatives. To maximize [return on investment] and improve outcomes, payers should integrate member perspectives at every stage — whether through AI-driven digital navigators that adapt to patient preferences, co-designing AI-enabled care management tools with member insights, or embedding real-time feedback loops that refine predictive algorithms based on patient-reported outcomes. Without member-centric AI strategies, health plans risk developing sophisticated tools that fail at the point of care, leading to disengagement, inequity and suboptimal outcomes.
Philip Randall. Director, Population Health and Community Programs at Banner | Aetna: The evolution of new roles within the healthcare workforce, both clinical and non-clinical, deserves greater attention. The industry is undergoing one of its most transformative periods in decades, driven by the growing demand for holistic, coordinated care and effective cross-functional collaboration — as well as more constricted operating budgets. This shift has created a need for innovative roles that blend diverse skill sets, moving beyond traditional healthcare job functions.
As these roles emerge, they are reshaping how we recruit, manage and develop talent. Employers are increasingly taking on the responsibility of training and upskilling their teams, bridging the gap until professional societies and educational institutions adapt to these new demands. By addressing this evolution head-on, we can better prepare our workforce to meet the challenges of modern healthcare and deliver more impactful, patient-centered care.
Saria Saccocio, MD. Chief Medical Officer at Essence Healthcare: Healthcare leaders would likely agree that patients are best served in the right place, at the right time, with the right provider. The question is what is right? Our healthcare industry is incentivized to deliver care at any place, any time, regardless of the most cost-effective or clinically relevant location. Patients are treated in the emergency department chronically for hypertension, stable iron deficiency may be managed at a hospital infusion center, and procedures that can be performed at ambulatory surgical centers occur in hospital operating rooms. When all stakeholders, including the patient, are incentivized to deliver and receive right care in the right place, then value-based health is optimized for safety, quality and right-sized cost.
Ilan Shapiro Strygler, MD. Chief Health Correspondent, Medical Affairs Officer and Senior Vice President at AltaMed Health Services: A critical gap in healthcare discussions is the need to prioritize prevention, improve continuity of care across different payors and protect Medicaid. Prevention remains underfunded despite its long-term cost savings and impact on chronic disease management. Fragmentation in care transitions from patients between different insurance payors creates inefficiencies and worsens health outcomes, and reduces the possibility to do long-term planning for everyone involved. Additionally, Medicaid plays a vital role in ensuring access to care for millions, yet ongoing policy threats put its sustainability at risk. Addressing these gaps is essential to building a more effective, equitable and cost-efficient healthcare system.
Jennifer St. Thomas. Senior Vice President, Commercial and Medicare Markets at Mass General Brigham Health Plan: We are experiencing a loneliness epidemic that was accelerated by factors such as the pandemic, social media use and others. Lack of connection can have profound impacts on the mental health of people of all ages — but especially among teens and seniors. As a health plan that’s part of an integrated healthcare system, we are continuing to expand options for teens and families that address these concerns and prioritize mental health as key to overall wellbeing.
Don Stiffler. Chief Revenue and Growth Officer, Commonwealth Care Alliance: Healthcare affordability for all. Doing so in a reasonable, manageable way that has a positive impact on the payers, the member and the provider of care. There are so many great alternatives in our healthcare sector/industry that truly do look at ways to make healthcare more affordable and at the same time provide better results and higher satisfaction with the members being served. One such example of this closely associated with CCA is instED, a mobile integrated health platform. instED is a convenient, innovative and practical alternative to visiting an emergency department for non-emergency care.
Chandni Sud-Thavakumar, EdD. Vice President, Performance Operations at Mass Advantage: In the past decade, the healthcare system has started to shift from fee-for-service to value based care models. In that shift, a focus on outcomes and reduction of unnecessary waste has begun. However, what is not a priority today is how to best aggregate real-time data from various entities to allow providers and payers to have the full picture on how best to care for the population. Not only will this reduce unnecessary care and strengthen outcomes, but it will also empower everyone to be in charge of their care and improve the experience of having their full care team aware of the history of the care they received.
Ty Wang. Co-Founder and CEO of Angle Health: One critical topic that leaders need to keep in mind as the pace of technological innovation accelerates is the responsible deployment of AI in healthcare. AI has the potential to enhance diagnostics, streamline administrative tasks and personalize treatment plans, but there’s also a risk of bias in algorithms, lack of transparency in decision-making, and unintended consequences in cost predictions and coverage approvals. We see AI’s ability to improve efficiency and expand access to care, but it must be implemented thoughtfully to avoid reinforcing disparities. Additionally, as virtual care and AI-driven diagnostics grow, data privacy and patient agency must remain a priority. At Angle Health, we take a human-in-the-loop approach to AI, focusing not just on speed to innovation but on building trust and accountability in these emerging technologies.
Meredith Williams, MD. Vice President, Clinical Affairs at Oscar Health: Medicine has long focused on delivering personalized care. Healthcare and insurance has tended to head in the opposite direction — creating products and services for the average need. To improve healthcare we must reorient it to solving for the individual — not the average. Through the individual market, 24 million Americans today already choose the plan and solutions that are right for them. As an industry, we must continue listening to the consumer, designing plans for them as people — not statistics. We must continue to focus on plans that specifically address conditions such as diabetes, asthma or other chronic conditions, to help people live longer, healthier lives.
Samuel Wollner. Vice President, Strategy and Partnerships at EmblemHealth: The pace of adoption of value-based payment is not talked about enough in healthcare. As policymakers in Washington consider ways to increase the efficiency and affordability of Medicaid and other public programs without harming beneficiaries, VBP offers significant potential: collaborations between payers, providers, and pharmaceutical companies have demonstrated VBP arrangements improve health outcomes, encourage more primary care, and make healthcare more affordable. For example, at EmblemHealth, we know from experience that our members who work with contracted providers in well-crafted VBP arrangements are more likely to get annual check-ups, be screened for chronic diseases and preventable cancers and are less likely to be hospitalized. These partnerships among private sector groups should be an example for policymakers as they consider solutions to reduce federal spending while ensuring Medicaid and other public programs continue to serve their vital roles. As an industry, we also need to continue the dialogue about why VBP adoption has lagged, if we need government intervention to encourage it, and what types of government policies would be most effective.