Rising patient expectations, financial pressures, regulatory complexity, and a shift toward value-based-care (VBC) and payment for outcomes, will shape the healthcare landscape of 2025. Payers (Health Plans) and Providers (Health Systems) must navigate these challenges while striving for operational excellence, improving patient outcomes, staying compliant and ensuring financial sustainability.
Health System leaders are turning to enterprise software solutions to navigate these complexities. LowCode integrated platforms leveraging Electronic Document Management (EDM), Business Process Management (BPM), Customer Communication Management (CCM), Provider Lifecycle Management (PLM), Appeals & Grievances (ANG) powered by Enterprise AI, and Enterprise Cloud software help Providers and Health System leaders redefine and transform how healthcare organizations operate.
These technologies offer a unified approach to overcoming the common challenges faced by payers and providers thus pave a pathway to innovation and efficiency. This article explores clear and present challenges and emphasizes how enterprise software can address them.
The healthcare system is grappling with numerous challenges impacting payers and providers. After analysing multiple sources, we can narrow down several key issues these stakeholders must navigate to ensure effective and equitable healthcare delivery.
1. Financial Pressures and Cost Management
One of the foremost challenges is the soaring cost of care. Payers and Providers are under intense pressure to manage and reduce these costs without compromising the quality of care. Several factors, including inflation, the cost of advanced medical technologies and equipment, and the increasing prevalence of chronic diseases, are driving healthcare costs. For instance, BCG notes that health insurance premiums are expected to increase sharply due to the care backlog and cost increase, putting an additional strain on families and businesses.
2. Fragmented Data and Interoperability
Data, Images and Documents (DID) fragmentation remains a significant issue for both Payers and Providers. The lack of seamless integration between disparate systems, from Electronic Health Record (EHRs) to Claims Administration System (CAS) to Care Management System (CMS) , results in inefficient data & document exchange. Providers struggle with incomplete patient data and images, which can compromise care, while payers often face delays in claims adjudication and processing.
In 2025, data interoperability will be paramount as healthcare organizations seek to manage value-based care more effectively. Without integrated systems, payers and providers will find it difficult to achieve coordinated care or manage population health strategies. These technologies promise improved patient care and operational efficiency but require substantial investment and training. Moreover, the integration process can be complex and disruptive if not managed properly.
3. Regulatory and Policy Changes
Regulatory ASKs and Regulatory changes continue to pose significant pressure for the leaders and executives of Health Plans and Providers to stay compliant. The implementation of the Inflation Reduction Act and the new anti-competition policies by the FTC add layers of complexity to the operational landscape. These policies influence pricing, market competition, and overall industry stability, necessitating strategic adjustments from both payers and providers. Similarly, as suggested by AHDM, payers will need to carefully analyze the effects of the IRA and develop strategies to effectively manage their Medicare and commercial specialty benefits in this shifting landscape.
4. Labor Shortage
The healthcare sector faces a critical labor shortage (both clinical and technical), significantly impacting its ability to deliver high-quality care. The pandemic further exacerbated this issue, highlighting the need for a resilient and well-supported workforce. Providers and Health Systems are exceptionally strained, as they must balance maintaining adequate staff levels for quality patient care while effectively managing operational costs, revenue and margin goals. Even for not-for-profit Hospital and Health Systems, the escalating cost of operations and technology is putting huge pressure on the business viability. This challenge affects the clinical and non-clinical staff, influencing everything from direct patient care to administrative functions.
Health systems urgently need a larger workforce. Although the global economy could create 40 million new health-sector jobs by 2030, the World Health Organization anticipates a shortfall of 9.9 million physicians, nurses, and midwives globally over the same period. This gap highlights the pressing need for strategic initiatives to attract, train, and retain healthcare professionals worldwide.
5. Value-Based Care Adoption
Improving the quality of care while managing costs can be critical for healthcare providers. Payers are increasingly leveraging data-driven and outcome-based approach to benchmark and enhance the quality of care. For example, advanced analytics on Data, Images and Documents (DID) can help identify areas for cost savings and quality improvements, such as reducing the over-prescription of brand-name drugs in favor of generics. This helps manage costs and ensures that patients receive effective treatments. As a result, adopting value-based care models is a complex but necessary shift. Aligning incentives with patient outcomes requires comprehensive data analytics and strategic partnerships. McKinsey stresses the importance of collaboration between payers and providers to effectively design and implement these models.
6. Patient-Cantered Care and Consumer Expectations
The rise of consumerism in healthcare is driving demand for transparency, convenience, and personalized care. Patients now expect real-time access to health information, seamless care experiences, and greater involvement in their care decisions. Providers are tasked with delivering patient-centered care that meets these expectations, while payers must offer transparency in coverage options and user-friendly self-service tools.
Software organizations are critical in addressing the challenges payers and providers face. By leveraging advanced technologies, these organizations can enhance operational efficiency, improve patient care, and drive better health outcomes. Here’s how:
- Streamlined Data Management with Electronic Document Management (EDM): Efficient data management is crucial for payers and providers. Enterprise Document Management (EDM) systems help bridge the gap between siloed data by centralizing patient records and automating document workflows. According to EPAM Systems, organizations implementing data integration can reduce costs by up to 30% while improving clinical outcomes. EDM allows for real-time access to critical information, which improves care coordination, claims processing, and compliance efforts. This integration not only reduces administrative burdens but also enhances the decision-making process.
- Telehealth Solutions: The COVID-19 pandemic has accelerated the adoption of telehealth services, transforming care delivery. Software organizations have developed platforms that enable remote consultations, making healthcare more accessible. The American Hospital Association reported that telehealth visits surged from approximately 840,000 in 2019 to over 52 million in 2020, illustrating the significant shift in care delivery methods.
- Predictive Analytics with Enterprise AI: Advanced predictive analytics, especially those powered by Enterprise AI, can empower healthcare organizations to identify at-risk populations and optimize treatment plans. A study by McKinsey indicates that organizations utilizing predictive analytics can achieve a 20% reduction in readmission rates for chronic disease patients. AI allows providers to predict patient risk, automate clinical workflows, and improve diagnostic accuracy, while payers can detect fraud and optimize claims processing.
- Business Process Management (BPM) for Efficiency: BPM platforms enhance efficiency by automating and optimizing core processes for both payers and providers. From claims adjudication to care coordination, BPM helps eliminate manual bottlenecks. Providers can automate patient onboarding and appointment scheduling, while payers can streamline claims management and contract negotiations. This approach can reduce turnaround times and improve accuracy across various workflows.
- Patient Engagement Tools through Customer Communication Management (CCM): Enhancing patient engagement is vital for improving health outcomes. Software solutions offer tools that promote active patient participation in their healthcare journey, such as mobile apps for medication management. HealthTech Digital states that engaged patients are 30% more likely to adhere to treatment plans. CCM platforms enable healthcare organizations to deliver personalized, omnichannel communications that can foster stronger patient relationships and improve adherence to care plans.
- Provider Lifecycle Management (PLM) for Streamlined Operations: Managing provider networks is complex and time-consuming. PLM software simplifies this process by automating provider onboarding, credentialing, and performance monitoring. This helps payers expand their networks faster and reduces delays in credentialing for providers, aligning them better with value-based care goals.
- Compliance and Regulatory Support with Appeals & Grievances (ANG) Management: Navigating complex regulatory requirements is a significant challenge for healthcare organizations. The ANG management software automates the process of submitting, tracking, and resolving appeals and grievances to ensure timely responses and reduce the risk of regulatory penalties. This functionality helps improve member satisfaction while facilitating faster resolution of claims disputes and ultimately results in better cash flow.
- Enterprise Cloud for Scalability and Flexibility Cloud-based enterprise software enables payers and providers to scale operations and access real-time data across geographically dispersed locations. This reduces infrastructural costs and ensures compliance with evolving security standards.
Cloud infrastructure facilitates seamless updates, allowing health systems to remain agile in a rapidly changing regulatory environment while keeping pace with emerging technologies like telehealth and remote monitoring.
By harnessing the power of technology, software organizations can help healthcare payers and providers navigate the industry’s tricky complexities with ease. This collaboration fosters a more efficient, patient-centred system that is better equipped to meet the population’s evolving needs. As the healthcare landscape evolves, advanced technologies will be instrumental in surpassing current challenges and driving sustainable growth.
By
Manish Jaiswal, MBA
VP & Global Head – Newgen Health
646.644.3049
Manish-jaiswal@newgensoft.com
Newgen Software, Inc.
