In our previous blog post, we explored how payers are rethinking affordability in 2026. They are moving beyond short-term cost control measures to examine the structural drivers of spending, invest in early intervention, and foster greater alignment across the healthcare ecosystem.
Building on that perspective, the next critical shift in 2026 is operational. Payers need systems, processes, and technology that make improvements possible. Fragmented platforms, manual workflows, delayed decision-making, and limited real-time visibility are not just operational challenges. They are barriers to scaling value-based care, preventive programs, and personalized member engagement.
When healthcare costs are discussed, the focus is often on clinical drivers such as specialty drugs, chronic disease, and hospital pricing. Those factors are critical, but they are only part of the picture. Administrative complexity also plays a major role.
Estimates suggest that administrative spending accounts for a substantial share of total healthcare costs in the United States. Much of that is driven by processes that remain highly manual or fragmented, including:
These inefficiencies create a ripple effect across the system. Delays in approvals can slow access to care. Manual processes increase provider burden and contribute to burnout. Denials and appeals introduce rework that consumes time and resources on both sides.
Improving these processes is not just about efficiency. It directly impacts cost, care delivery, and the overall experience for providers and members.
Over the past decade, payers have invested heavily in digitizing core processes. Paper-based workflows have been replaced with electronic systems, and manual touchpoints have been reduced in some areas. However, digitization alone does not eliminate inefficiency. In many cases, it simply replicates existing processes in a digital format without improving how decisions are made.
Automation technologies help address this gap. Robotic process automation and rules-based engines can handle repetitive tasks such as claims intake, data validation, and prior authorization routing. This improves consistency, reduces processing time, and minimizes human error.
As a result, operations teams can shift their focus from routine processing to exception handling and higher-value activities. Over time, this creates a more scalable operating model that can support increasing volume and complexity without a corresponding increase in administrative cost.
Beyond automation, payers are embedding intelligence into workflows. Predictive models can identify members at risk of high-cost events, such as hospitalizations or complications from chronic conditions. AI can support staff in areas such as claims review, fraud detection, and prior authorization by surfacing relevant information and recommendations.
The value of these technologies lies in improving decision quality. Instead of relying solely on retrospective review, organizations can act earlier and with greater precision. This supports more appropriate care pathways, reduces unnecessary interventions, and helps ensure that resources are directed where they have the greatest impact.
Importantly, these capabilities are most effective when integrated into day-to-day workflows rather than used as standalone tools. When insights are delivered at the point of decision, they are more likely to influence outcomes.
Many payer processes still rely on lagging indicators, such as post-service claims adjudication or delayed cost analysis. This creates a reactive model where issues are identified after they have already occurred.
Cloud-based data platforms, unified data models, and interoperability standards such as FHIR and HL7 are helping shift this dynamic. By enabling faster and more consistent data exchange across payers, providers, and digital tools, they make it possible to act closer to the point of care.
This includes capabilities such as:
Increasing the speed and accuracy of these decisions improves coordination and helps avoid delays that can lead to higher downstream costs.
Member expectations are also influencing how payers think about operations. Consumers are accustomed to digital experiences that are transparent, responsive, and personalized, and those expectations are carrying over into healthcare.
In response, many organizations are investing in digital engagement capabilities, often described as the “digital front door.” These include:
These capabilities do more than improve experience. They influence behavior. When members have clearer information and guidance, they are more likely to select appropriate sites of care, follow recommended treatment plans, and engage with preventive services earlier.
As a result, member experience becomes a meaningful lever in managing cost and improving outcomes.
Together, these operational and technological advances create the foundation for a new payer model. In this model:
Achieving this requires more than isolated solutions. Integrated data platforms, interoperable systems, and governance models are essential to ensure that data flows consistently across the organization and that decisions are aligned.
Cloud-based architectures play a key role by enabling scalability, flexibility, and secure data sharing across internal teams and external partners. Without this foundation, even well-designed initiatives remain difficult to operationalize at scale.
While the direction is clear, execution remains complex. Many payers are still managing:
Modernization efforts require sustained investment and careful prioritization. At the same time, organizations must continue to meet near-term performance expectations, which can slow progress.
However, maintaining the status quo also introduces risk. As expectations from members, employers, and regulators continue to evolve, the gap between current capabilities and future needs is likely to grow.
Companies like Concord help payers navigate this complexity. By combining expertise in modern data platforms, interoperability, and intelligent workflows with deep healthcare experience, Concord enables organizations to reduce administrative friction, improve decision-making, and implement more proactive operating models while continuing to manage near-term demands.
If the first shift underway is about redesigning how healthcare is delivered and financed, the second is about building the operational and technological foundation to support that redesign. Without that foundation, strategies such as value-based care, preventive models, and personalized engagement will be difficult to scale.
With it, a different model becomes possible. One where:
This does not eliminate the need for cost management. It changes how cost is addressed by focusing on prevention, coordination, and better system design.
For IT and data leaders, this shift creates an opportunity to play a more central role. By enabling better data access, reducing operational friction, and supporting more intelligent workflows, technology can help translate strategy into measurable outcomes.
Ultimately, the payer of the future will not be defined solely by how effectively it controls cost. It will be defined by how well it uses data and technology to make better decisions across the entire care journey.
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