Is AI helping or hurting the payer-provider relationship?
In this episode of HL Shorts we hear from Evan Zaslow, Vice President of Payer Strategies at Moffitt Cancer Center. Zaslow dives into how the technology like AI has impacted payers and providers and how it could potentially impact this relationship in the future.
Curiosity, collaboration, and risk evaluation are key to this CFO’s strategy.
Whitney Bendel took over as CFO of Medical City Denton in August 2024. Now, roughly eight months into her role, she’s sharing what she is learning, working on, and looking out for as the financial overseer of a specialty advanced care center.
Medical City Denton is a 228-bed, acute care hospital with more than 900 employees and 1,100 physicians in Denton, Texas. In addition to being a Level II trauma center, the organization is also a primary stroke center and an accredited chest pain center offering advanced open-heart surgery.
Prior to this role, Bendel served as CFO for Medical City Lewisville, where she contributed to facility-wide enhancements. During her tenure there and at Medical City Dallas prior to that, she helped to build processes that tracked the organization's volume, revenue and financials in support of the campuses' growth agenda.
Collaboration
Collaboration with clinical teams is key for organizational success. For Bendel, this collaboration is vital to making informed financial decisions.
“I stay very close to my clinical leaders. It is important for me to hear what is happening on the front line to ensure we are addressing their needs while staying aligned in our goals,” Bendel says.
“We meet regularly at a senior team, a director and manager level to discuss productivity, staffing, and contract labor management. This allows me to understand how I can support them,” Bendel says.
“We also have a multidisciplinary team of leaders that discusses throughput opportunities and length of stay to ensure we are getting our patients safely in and out of the hospital. The clinical leaders are also imperative when we increase capacity or add new service lines. We set up a task force to talk through many things including resources, equipment and supplies.
Challenges and Hurdles
One constant to Denton’s specialty care challenges is comprehensive coverage.
“I believe the organization as a whole is concerned about the premium tax credits set to expire in 2025 that will make health insurance more costly for those that have been able to access the marketplace plans and to be able to provide care for themselves and their family,” Bendel says. “That is the number one focus for HCA Healthcare and Medical City.”
As the country sees more medical debt, this will be a prominent issue for many health systems.
A recent report found that roughly 12% of U.S. adults (about 31 million) say they collectively borrowed an estimated $74 billion last year to pay for healthcare, either for themselves or a family member. Additionally, a majority of Americans, about 58%, say they are concerned they would experience medical debt if faced with any major health event.
Taking the Risk
Bendel shares that curiosity remains a vital component of her strategy as a finance leader.
“A mentor of mine told me to stay curious. When you are curious, you ask questions, and you find creative ways to solve problems. Or your curiosity could cause someone to think of a situation differently,” Bendel says. “So being curious is really important to understand the issues and think creatively at solutions."
Being curious goes hand-in-hand with exploring unconsidered options and creating pathways to take risks that can ultimately pay off for the health system.
“I am naturally conservative and more risk averse. However, experience has taught me that it is imperative to take risk in the right situations to continue to grow,” Bendel says.” If the business case supports the risk then go for it.
Here's how CFOs can leverage their unique position.
As health systems spend billions annually battling payers—CFOs have to recognize the power they have to turn financial losses into policy-driven reform. Healthcare CFOs must step up as strategic leaders to bridge the growing financial and operational divide between payers and providers. To drive real change, CFOs must move beyond financial strategy and into policymaking to advocate for fair reimbursement and operational sustainability.
Check out this infographic for three CFO tips for jumping into policy reform discussions.
The growing tension between payers and providers is no secret. And it's forcing CFOs to take action.
The following is an excerpt from our March cover story.
Providers have been fed up with payer behavior for decades; many have suffered financial turmoil from payer tactics, smearing contention across the picture of healthcare for everyone involved.
About 84% of health system CFOs cite lower reimbursement rates from payers as the top cause of low operating margins, according to a study published by the Healthcare Financial Management Association (HFMA).
Among HFMA survey respondents, 75% have also added more FTEs to handle insurance denials, and 63% have added staff to follow up on accounts receivable, both of which eat into a health system's budget just to keep up with payers.
Over the last few years some components of this dynamic between payers and providers have shifted, but arguably, not enough. There have been some wins, like increased transparency laws and modernized care models, but there have also been some losses, — and lawsuits — like payers using AI to inappropriately deny claims, fanning the flames of these disputes.
Even as recent as this month, health systems are opting out of settlements and choosing to fight back against payers with legal action. Dozens of health systems are currently suing Blue Cross Blue Shield for paying healthcare providers, "far less than they would have been paid in a competitive market."
Mayo Clinic is also currently suing Sanford Health Plan over $700K in unpaid medical bills for a patient that was treated over two years ago. Mayo said is not seeking payment from the patient.
It's instances like these that bring to the surface the strife between payers and providers, and patients that suffer.
Resentful Consumer Outcry
The murder of United HealthCare CEO Brian Thompson shone an uncomfortable, blinding light on the contention within healthcare; not between payers and providers—between consumers and the modern healthcare system.
The online backlash after Thompson's murder was nothing to shrug off, but in many ways, that's exactly what happened. Consumers used the opportunity to fire back over the struggles of obtaining affordable healthcare through today's insurers, painting a stark silhouette of spite against a horrific tragedy.
The harsh, inappropriate backlash from consumers took over the narrative for a brief second, but despite its widespread intensity, despite the decades of patients' rage that led to this horrific outcome, it didn't spark any significant change to healthcare or healthcare policies, it only brought about tension. Under this constant tension, cracks form, and systems break down.
"Though an unjustifiable action, we must recognize that there is a lot of friction that a lot of people, both payers and providers, know is there," said Rick Gundling, Senior Vice President for Content and Professional Practice at HFMA and a former CFO.
This incident was tragic and will always be tough to face. But the industry shouldn't let the discomfort of the situation muddy the waters of the underlying sentiment: many people have died because of denied care.
"It makes no sense to me that there is no true system that captures physical harm to enrollees related to denied or delayed prior authorizations," says Kurt Barwis, CEO of Bristol Hospital, registered lobbyist in Connecticut, and former governor of the American College of Healthcare Executives. "Healthcare is supposed to be evidenced based/do no harm … yet the use of prior authorizations gets a complete and total pass?"
According to a report by the Kaiser Family foundation, 19% of in-network claims and 37% of out-of-network claims were denied in 2023, for a combined average of 20% of all claims. All of this is not to say that payers undoubtedly carry all the blame, but rather that the American healthcare system has failed many, many people when they needed it most.
CFOs stand in a unique position that enables them to use their voice and expertise to advocate for policy reform. Read the full story to understand how, as well as the best strategies for seizing the opportunity.
Funding for healthcare technology and medical research are on the table.
The Trump administration has proposed downsizing the Health and Human Services Department, and CFOs need to be prepared for the potential effects to their health system.
Downsizing HHS particularly through the technology department and the Agency for Healthcare Research and Quality (AHRQ), could negatively affect healthcare. The impact could stretch from the technology infrastructure supporting electronic health records (EHRs) to the pace and quality of medical research. CFOs will need to adopt proactive strategies to minimize these impacts for their health systems.
Cybersecurity, Safety & CMS
Health systems look to HHS for guidance through items such as the HITECH Act. HHS also oversees certification of electronic health records for health systems. Under the Biden administration the HHS technology department saw a revamp and push towards supporting greater artificial intelligence adoption and innovation. With potential workforce cuts here, AI innovation and guidance could be impeded.
Politico reported that the Trump administration has already “wiped the department’s strategic AI document from the web and dismiss[ed] newly hired senior staff in charge of data, technology, and AI policy.”
Without the work that HHS does to enhance cybersecurity measurements, health systems could be more at risk. With cybersecurity risks ballooning in recent years, the potential for a cyber incident could grow even bigger. With the increasing push for interoperability across health networks, delays in technological advancements could also impede the seamless exchange of patient information, undermining hospital workflows, increasing administrative costs, and jeopardizing patient outcomes. This is where data integrity comes into question. As HHS potentially scales back its technology workforce, there may be fewer resources available to support data analysis, quality control, and compliance with federal regulations.
HHS also plays a crucial role in medical device safety through the FDA, as well as the cybersecurity measurements for these devices. Workforce reductions here could affect patient safety when it comes to these devices.
Implications for CMS may also come into play. With looming Medicaid cuts, reimbursement and governance in this sector will likely also be hurt. This could affect reimbursement for health systems, stressing health system finances even more.
For CFOs: these disruptions could lead to increased costs for managing internal IT teams, addressing data quality issues, ensuring medical device safety, and following up on Medicaid reimbursement
Research and Innovation Slowdown
Another area primed for workforce disruption is medical research and innovation due to staffing cuts at the Agency for Healthcare Research and Quality (AHRQ.) AHRQ plays a key role in supporting healthcare research, providing funding for innovative medical studies, and improving evidence-based practices. With fewer resources at this agency, research grants could slow down, and fewer studies might be funded, impacting the development of new treatments and technologies.
This could limit opportunities for hospitals to engage in clinical trials, access cutting-edge technology, or improve patient outcomes based on the latest evidence. The reduction in research funding could also spell trouble for areas like personalized medicine, chronic disease management, and health disparities.
For CFOs: Without access to medical advancements and cutting-edge treatments to drive patient volumes and new service lines, this may translate into lower revenue growth for health systems.
The CFO Guide
Invest in IT Infrastructure and Talent: CFOs should examine investments to strengthen their internal IT teams or partner with third-party IT service providers to ensure continuity in EHR management. By allocating a budget for proactive IT infrastructure upgrades, including cybersecurity measures, and data analytics tools, CFOs can minimize downtime and protect against potential breaches. Also, training internal IT staff to handle emerging technologies could reduce the health system’s dependence on external agencies.
Leverage Alternative Research Partnerships: CFOs can look for alternative funding sources for research and innovation. They can also increase their focus on developing in-house research programs and collaborating with clinical trial sponsors to ensure the continued flow of medical innovation.
Optimize Operational Efficiencies: CFOs can also focus on improving operational efficiencies across their organization including streamlining processes, reducing waste, and finding cost-effective solutions to maintain high-quality patient care.
Bonus strategy: CFOs can also get involved in policy discussions with their local representatives. By adding their voice to the pushback against actions that harm public healthcare, CFOs can help safeguard their organizations.
Industry-wide medical trend pressures contributed to Highmark’s 2024 losses.
Highmark Health Plans reported a negative operating performance, citing “industry wide medical trend pressures that continued into the fourth quarter of 2024” as the main contributor.
Despite this loss, two sectors within Highmark Health saw improved operating performance. Both United Concordia Dental and HM Insurance Group’s operating performances remained steady, fueled by increased dental membership and pricing discipline.
Allegheny Health Network (AHN), Highmark Health's provider network, also saw operating improvements that were driven by increased patient volumes across all care delivery areas.
Highmark Health’s balance sheet remained strong with $11.7 billion in cash and investments and net assets of $9.8 billion as of December 31, 2024.
The breakdown
Living Health model
A big part of Highmark’s health Plan membership increase came from efforts in its Living Health model, which allowed all eligible health plan members to gain access to the My Highmark app. The app connects patients to care in a variety of ways such as simplified bill payment and real time personalized recommendation through artificial intelligence.
“We also continue to expand our living health suite of digital and virtual health solutions. At the start of 2024, we launched mental well-being powered by spring health, increasing member access to mental health care by over 40%,” said Highmark Health president and CEO of Daivd Holmberg on an earnings call.
Highmark Health Plans
Operating revenue brought in from Highmark Health Plans was $22 billion, along with $166 million on operating losses through the year-end of 2024. The losses in this business sector were brought on by “increasing headwinds from rising health care usage, continued effects of Medicaid redeterminations, and high prescription drug costs, particularly GLP-1s,” according to the report.
“We're working through proper research strategies to address these challenges and improve performance. For instance, rapidly approaching a high cost of prescription drugs,” said Highmark Health CFO Carl Daley.
In 2024, Highmark also added a Medicaid segment in West Virginia, as well as entering the Southeastern Pennsylvania market, where it gained more than 70,000 new members. The organization also reported increased core health plan and Blue Card membership for Jan. 2025 compared to the same period last year, reporting 7.1 million members. Highmark Health Plans remain the largest health insurer in Pennsylvania, Delaware, West Virginia, and western New York.
Allegheny Health Network
AHN saw its total revenue increase by 9% year-over-year to $5.1 billion, and its operating loss also improved by 15% to $147 million compared to the same period last year. This was in part driven by increased patient volumes. In total, the provider network saw $115 million in earnings before EBITDA for the year-end of 2024.
Through Dec. 31, 2024, AHN saw patient volume increases in the following compared to the same period in 2023:
3% increase in inpatient discharges and observations
6% increase in outpatient registrations
5% increase in physician visits
5% increase in emergency room visits
Community and workforce
During the call, Holmberg addressed Highmark’s commitment to its communities, in which it has funded partnerships with community programs through its Highmark Bright Blue Futures program and donated roughly $53 million.
Holmberg stressed that as a nonprofit organization, commitment to its communities is top of mind. “No matter what happens in our industry, we will continue to invest in transforming health and creating high value jobs for the communities we serve,” Holmberg said.
Holmberg also addressed the layoffs made in January to its information technology subsidiary enGen, in which 207 employees were fired, including 86 in Western Pennsylvania and 41 in the central part of the state. EnGen jobs were also cut in eastern Pennsylvania, West Virginia, western New York, and other states.
“We will not cut costs anywhere that undermines our commitment to providing high quality care and creating remarkable health experiences,” Holmberg said. “Our approach does mean sometimes we eliminate jobs, but it also allows us to identify opportunities to shift people into new roles and create new high value jobs. We hired 6000 people in 2024. That's also part of our performance story.”
One in three Americans don't seek needed healthcare due to costs.
CFOs are charged with doing everything they can to lower costs of care within their health systems. And yet, healthcare is still generally unaffordable for so many.
A recent study shows that Americans borrowed about $74 billion last year to pay for healthcare.
The report found that roughly 12% of U.S. adults (about 31 million) say they collectively borrowed an estimated $74 billion last year to pay for healthcare, either for themselves or a family member. Additionally, a majority of Americans, about 58%, say they are concerned they would experience medical debt if faced with any major health event.
Here are three strategies that CFOs can examine to help make healthcare more affordable for their communities.
Higher volumes, better reimbursement rates and more efficient labor spending helped the health system bounce back.
Providence has made an impressive rebound in its Q4 2024 reports.
The Seattle-based non-profit health system reported higher volumes, better reimbursement rates and more efficient labor spending, all of which helped to cut its 2024 operating losses nearly in half.
Earlier this month Providence reported an operating loss of $644 million (-2.1%) across 2024. This is a big improvement on the $1.17 billion operating loss, and a grim -4.1% operating margin, that the health system saw at the end of 2023. This loss included $183 million in “reconstruction costs related to asset rationalization, employee reductions and other items,” according to the report.
Across the health system, operating revenues grew 7% year over year to $30.7 billion (5% when excluding a $426 million net gain in the first quarter). The report highlighted that this growth was spread across all operating categories.
Net patient service revenues also grew, rising 7% due to improved rates and higher volumes. This was helped by a 3% decrease in acute patients’ length of stay “due to improved access to post-acute care.”
Pro forma operating EBITDA for fiscal year 2024 and deficit of revenues over expenses from operations, excluding restructuring costs, were $989 million and $461 million, respectively. This represented a $487 million improvement from the prior year and an improvement of close to $1 billion in the last two years.
This improvement comes despite several struggles throughout the year related to regulatory changes, strikes and lower-then-expected Medicare rate increases.
“Meanwhile, all core operating metrics continued to improve,” the report also noted. “Notably, agency spending was 70 % lower than the peak in 2022 and case mix adjusted length of stay returned to pre-pandemic levels.”
The system also saw robust investment gains of $488 million for fiscal year 2024, bringing total unrestricted cash and investments to $8.2 billion as of December 31, 2024.
“We are proud that Providence continues to serve more people in need year over year even as macroeconomic and regulatory pressures continue,” Providence CFO Greg Hoffman said in a press release. “While we have made significant progress on our renew and recovery strategies post-COVID, we are not taking it for granted and are practicing continued operational focus and discipline to ensure long-term sustainability, which will position the ministry to thrive for years to come.”
The Cost of Strikes
One of Providence’s biggest hurdles was its nurses’ strikes, which cost the health system an estimated $25 million a week for 2,000 replacement nurses to replace the more than 4,000 who went out on strike. The strike by nurses with the Oregon Nurses Association (ONA) against Providence began on January 7 and ended on February 24, 2025. Nurses were able to ratify their contracts, ending the strike that lasted nearly six weeks.
CFOs should note the costly repercussions of strikes and work to ensure they can be prevented. To avoid strikes, CFOs should prioritize a stable workforce by supporting employee well-being, and addressing burnout through tools and programs that benefit nurses and physicians in their daily tasks.
One in three Americans don't seek needed healthcare due to costs.
Healthcare is unaffordable. Shocking, right?
A recent report found that roughly 12% of U.S. adults (about 31 million) say they collectively borrowed an estimated $74 billion last year to pay for healthcare, either for themselves or a family member. Additionally, a majority of Americans, about 58%, say they are concerned they would experience medical debt if faced with any major health event.
The research, from a Gallup poll and the West Health Gallup Healthcare Affordability Index, finds that two groups are fueling this increase in medical debt. The percentage of adults aged 50 to 64 who can afford care dropped from 63% to 55%, while the number of adults 65 and older who can afford to pay for their care dropped from 79% to 71%, bringing the total percentage of Americans able to afford healthcare down to 55%, a new low and a six-point decline since 2022.
The study shows that about one in three Americans (about 72 million) don't seek needed healthcare due to costs. This includes an estimated 8.1 million Americans age 65 and older.
Further, almost one-third of Americans expressed concern about their ability to pay for needed prescriptions over the next year, jumping from 25% in 2022.
This research says a lot. Healthcare is generally unaffordable to many Americans but older Americans are the hardest hit. This, coupled with threats of Medicare and Medicaid cuts, paints a grim picture for public health. Americans owe at least $220 billion in medical debt, according to a KFF study.
The Health System Sponge
At the HealthLeaders 2025 Revenue Cycle Exchange, many executives expressed frustration with medical debt. When patients can't pay, and in light of new policies that take medical debt out of credit scores, providers take on the risk. It's not uncommon for health systems to wipe out medical debt instead of deploying more dollars to chase down these outstanding bills.
"Margins are getting thinner and thinner for hospitals as costs continue to rise," said Elena Barberwis, VP of Finance for both Trinity Health Holy Cross Health and St. Mary's Health Care System. "Prices continue to rise on drug costs. Things are not getting any cheaper, especially with inflation."
The CFO Playbook
CFOs are charged with doing everything they can to lower costs of care within their health systems. And yet, healthcare is still generally unaffordable for so many.
Healthcare needs more effective strategies, developed by both payers and providers.
The Payer's Part
A study from the National Association of Insurance Commissioners found that payer net income actually decreased 14%, from just over $18 billion to approximately $16 billion, for the first six months of 2024 compared to the same period last year. Despite that decrease, the health insurance industry recorded a 17% ($1 billion) increase in net investment income earned.
CFOs will need to work hard to ensure that when they enter a contract with a payer, the risk is more equalized. By pushing back on hardball payer tactics, CFOs can work toward care models that don't let the organization drown in losses when patients can't afford care in an unequal system.
Some strategies CFOs can use when working with payers:
Apply pressure: Don't accept poor performance for inadequate rates
Drive the narrative: Reinforce the need for partnership, patient care over profits
Communicate: Educate leaders, patients, referring physicians on challenges.
No Delegating: Payers try to siphon off leadership tasks to minimize their input. Don't let that happen.
Stay the course: Be patient
Review deliverables: Hold payers accountable. No two negotiations are the same.
Consider creating a national payer scorecard: Keep track of the reputations, strategies and tactics of every payer your organization does business with.
Reaching for Reform
This issue doesn't end with payers and better contracts. Healthcare executives need to recognize that reform must come from all departments.
CFOs should recognize their potential in the fight for healthcare reform. Cuts to Medicare and Medicaid would wreak havoc on an already struggling healthcare system. By using their position and voice to advocate for regulatory reform, CFOs can help drive the changes they want — and need — to see for their organizations. Without this vital tactic, reform for health systems finances will be slowed, and the possibility of it could disappear altogether.
The opioid epidemic has affected hospitals, both clinically and financially, for almost 30 years.
More than1,000 acute care hospitals will receive a share of $700 million as part of the settlement of class action lawsuits against several pharmaceutical companies accused of helping to cause the opioid abuse epidemic.
The agreement condenses four separate class-action settlements against Cencora (formerly AmerisourceBergen), Cardinal Health, McKesson, Johnson & Johnson, Teva and Allergan, among other defendants.
According to the lawsuit, the defendants either misrepresented the risks and safety precautions correlating to opioid use, did not properly examine suspicious orders or filled prescriptions that were not written for approved medical purposes.
For this settlement, the drug companies have agreed to pay $651 million in compensation “for the past and future costs for treatment of opioid abuse and community outreach programs to address the epidemic,” according to a press release from Burns Charest, the Dallas-based law firm representing the hospitals.
Additionally, another $49 million will be used to supply hospitals with Naloxone over the next seven years for opioid abuse treatments, according to the law firm.
Many lawsuits have been filed with relation to the epidemic. Notably, drug giant Purdue Pharma declared bankruptcy in 2019 after a slew of lawsuits. Even this year, settlements are still rolling out for the mayhem caused by the extremely addictive opioid Oxycontin..
For Hospitals: The providers eligible for this settlement generally consist of non-governmental acute care hospitals that treated patients diagnosed with an opioid-related condition between January 1, 2009, and October 30, 2024, according to the settlement website.
If a hospital submitted a valid claim by March 4, it is entitled to either a $5,000 “quick pay” or a higher amount based on more detailed documentation of the costs incurred.
A Light on Destruction
Hospitals have been greatly affected by the epidemic, which began in the 1990s as drugmakers flooded the market with opioid-based drugs. According to a 2021 study, the epidemic resulted in annual costs related to overdose, misuse and dependence of:
$35 billion in health care costs;
$14.8 billion in criminal justice costs; and
$92 billion in lost productivity
According to the Centers for Disease Control and Prevention, more than 100,000 Americans died of an opioid overdose in 2021. Although opioid deaths have declined in recent years, the death toll still stood at roughly 83,000 as of September 2024.
Studies have shown that improving access to evidence-based treatments for OUD (opioid use disorder) has been associated with a savings of $25,000 to $105,000 per person in lifetime healthcare costs.
CFOs need to ensure they are calculating the cost of opioid care in their organizations and understanding how and where they can apply for reimbursement. They should also be working with clinicians to understand how this epidemic has an ongoing effect on hospitals, with regard to outcomes, care costs and other resources.
Many experts suggest that overcoming the opioid epidemic must have a collaborative healthcare approach. Health systems can look to participate and invest in partnerships, programs to evaluate and act on efforts to chip away at the opioid crisis.
