Healthcare in Transition: What to Expect in the Next 12–24 Months

Healthcare in Transition: What to Expect in the Next 12–24 Months
By Michelle Bounce, SVP of Business Transformation, VBA

As we look ahead to the next 12–24 months, the healthcare landscape is poised for significant changes driven by both political and economic forces. With a new administration in office, the stage is set for a series of regulatory shifts and market adjustments that will impact every corner of the healthcare industry. Understanding the historical context and anticipating the administration’s strategic priorities will be key to positioning ourselves for success in this evolving environment.

During his last term, President Trump made significant changes in the healthcare space.  These included No Gag Clause provisions, hospital price transparency and shoppable tools, the No Surprise Act, RxDC reporting requirements, Qualifying Payment Amount and Independent Review Processes as part of the price transparency initiative, MRF requirements, privatization of healthcare through the expansion of Medicare Advantage Plans, and expansion of Associated Health Plans. 

In addition to this, the unemployment rates (pre-Covid) were the lowest they had been in generations.  This created more competition within our industry to snag any talent with any training or industry knowledge.  In doing so, wages for roles like account managers, eligibility specialists, and claims examiners skyrocketed.  Furthermore, most TPAs were not equipped with the appropriate resources (technology or human) to address the legislative requirements.

Now, we need to factor in RFK Jr. who is a strong advocate for reversing the chronic disease epidemic in our country.  He will be eager to prove his hypothesis here using data and science.  He believes that the industry has too much influence and will likely stay focused on PBM regulations, disease management mandates, wellness incentives, and removal of vaccine mandates.

Given what we know, what should we expect from this administration?

• Expansion of price transparency regulations. Trump believes healthcare requires price tags just like any other item we purchase to create competition, reduce prices, and improve quality. In fact, on February 25, 2025, he signed an Executive Order to further the goal of price transparency. This Order aims to move from price estimates to Actual Prices and indicates action may be taken to make ricing comparable between hospitals and insurers. Could this be the beginning of the end for the hospital charge master as we know it?
• Expansion of No Surprise Act to include an increase in the dollar threshold that can be reported to credit agencies which will increase the number of Open Negotiations and Independent Reviews. There is significant uncertainty around how the increased number may be managed given the cuts to government spending. However, I would not expect this to stop the momentum. A combination of increased dollar thresholds or no dollar thresholds along with the expansion of price transparency will serve to meet a significant portion of his stated goals.
• Continued efforts to privatize the healthcare sector. This could include further expansion of Medicare Advantage Plans.
• Expansion of the regulations for Associated Health Plans.
• Heavy focus on expanding the RxDC reporting requirements in an effort to regulate pharmaceutical pricing.
• Less likely but possible given leaning of RFK Jr. – Disease Management Mandates. I would expect this to come in the form of a requirement to report based on chronic disease state. Similar to MRF requirements but leaning toward demographic data, diagnostic data, and geographic data.
• RFK Jr. has historically been vocal in his opinion of GLP-1s.This “new” weight loss remedy likely has a pretty big target on its back.
• Removal of gender affirming care requirements for minors.
• Federal subsidy for in vitro fertilization.
• Increase to minimum wage and significant reduction in unemployment numbers.

If there is one thing that we know about this administration, it is packed full of people who do hesitate to act.  The economy will remain at the forefront of the discussion, but we are not likely to see a reprieve from significant changes to the healthcare sector.  We certainly have some challenges ahead but should not lose sight of the significant opportunities these changes may create for our industry.  What can we do to prepare ourselves to be in a position to take full advantage of the possible opportunities? 

Here is some food for thought:  

• Shore Up Your Processes on Existing Reporting Requirements Now. The first several rounds in transparency regulations created a very heavy burden for the industry. TPAs were often ill equipped to gather the information required from their systems and did not have the technical capabilities to report the information within the scope of the regulations. RxDC reporting was particularly difficult and is still being pieced together between the TPA and the PBM in many instances. This second round of transparency will have a heavier focus on pharmacy data and actual costs. It is even probable that we may see the addition of diagnostic reporting requirements.
• Open Negotiations and Independent Reviews will increase. Currently, many in our industry have not given full consideration to how they track and report on open negotiations. This means that many TPAs are not doing nearly enough to defend the allowable charge. As a result of this, most IDRs rule in favor of the provider. This fact alone will likely be ammo used by the opposition to indicate that hospital pricing is not excessive. The new administration is not likely to accept this at face value. We should expect that this will come to light and garner significant scrutiny. Any administrator who is not conducting the open negotiations or independent reviews at the highest level may find themselves in hot water very quickly. The administration will be looking for fraud, waste, and abuse here. Make sure that you have created criteria and processes on open negotiation based on bill type that can be followed and documented. This will allow an administrator to prove that they followed a clear and clean process for defending the amount paid.
• Under his first term, Trump brought monthly premiums for Medicare Advantage to the lowest they had been in 13 years. He credits this, in large part, to expanding these plans in the private sector, creating more plan options and better pricing. These same premiums have increased back up to where they were 8 years ago. There may be significant opportunities to offer and administer these plans in the coming months.
• Expansion of Associated Health Plans similar to MEWAs but with a lot less regulation and a lot more flexibility. This will allow for multiple employers to join together under an association to achieve the same buying power as larger employers.
• Document All Institutional Knowledge and Processes. Increases in minimum wage and lower unemployment rates created disruption in our industry during his last term. Luckily, the increased opportunities and reduction of taxes helped offset this.The TPA industry is a pretty small bubble. We have a finite number of people who have been working in the industry for 5+ years. Those people, particularly in claims, eligibility, and account management, will remain in high demand. This will become more difficult given that those people with 5+ years of experience are largely over the age of 50 right now. We are in an industry in which experienced claims examiners, enrollment specialists, and account managers are becoming difficult to find and even more difficult to keep. For example, the average salary for a medical claims examiner in 2018 was showing around $47,523.Compare that to the average salary for this same position in 2023 which is listed at $75,050.

The next two years promise to be pivotal for the healthcare industry, with increased regulation, shifting market dynamics, and evolving political priorities shaping the path forward. While these changes present undeniable challenges, they also open the door to new opportunities for those prepared to adapt. By strengthening internal processes, staying ahead of reporting requirements, and anticipating regulatory shifts, industry leaders can position themselves to thrive in a rapidly changing landscape. Now is the time to prepare, strategize, and seize the opportunities that lie ahead.