What 5 Managed Care Trends Experts Say You’re Not Watching Closely Enough

Lately in managed care, certain trends have been in the spotlight more than others—including the growth of GLP-1 drugs, the rise of AI tools and the rules under the Inflation Reduction Act (IRA)—which are reshaping the Medicare Part D benefit by capping out-of-pocket costs, limiting insulin copays and enabling Medicare to negotiate drug prices.

While these topics make headlines, other significant movements in managed care aren’t getting enough attention.

Managed Healthcare Executive asked several experts in healthcare and managed care to share the trends they think the industry is overlooking. From rising costs and data challenges to shifts in how care is delivered, these are the issues that could have a major impact — and deserve a closer look.

Trend 1: Increased Utilization Driving Higher Costs

Increased utilization is a major trend that everyone in managed care needs to pay closer attention to, according to Lynn Nonnemaker, Ph.D., senior director at McDermott+ Consulting. It first became evident in 2024 when Medicare Advantage plans reported higher-than-expected utilization rates, a pattern that appears to be continuing into 2025, as UnitedHealthcare and other payers have recently indicated, Nonnemaker said.

Lynn Nonnemaker, Ph.D.

Early in 2024, CMS statements suggested skepticism about whether there was a real shift happening in Medicare utilization trends, she added. However, more recent data from payers points to increased use of both medical services and specialty drugs.

“This affects not just payers, but everyone involved in the value-based care chain, including providers who take downside risk,” Nonnemaker said.

Trend 2: Rising Healthcare Costs Demand Better Early Engagement

Rising healthcare costs—driven by high drug prices, inflation, an aging population and increasing chronic disease — remain the biggest financial burden for Medicare Advantage plans, according to Bob Farrell, CEO of mPulse.

This makes early detection, screenings, annual wellness visit reminders and health risk assessments even more crucial, however, digital engagement tools are often overlooked for their ability to both control costs and improve outcomes.

Bob Farrell

“Many organizations struggle to keep up with the monitoring and management of these processes, as well as integrating the results of both into overall care management programs,” Farrell said.

However, organizations that invest in digital strategies are seeing strong returns, he said.

For example, an mPulse client reduced call center demand by 37% and achieved a 60% response rate through two-way text messaging for member engagement; medication adherence reminders prompted responses from 41% of patients; a large integrated delivery system lowered its no-show rate by 20% while boosting patient satisfaction to 97% through appointment reminders and an online wellness academy achieved a 75% course completion rate, with steady growth in enrollment month over month.

Trend 3: Organizing Care Around Expensive, Blockbuster Drugs

High-profile, expensive drugs such as GLP-1s for diabetes and cell-based gene therapies for sickle cell disease often generate excitement for their potential to transform care. However, there is still a lot of waste and false starts when it comes to actually improving patient health.

Margaret O'Kane

Margaret E. O'Kane, president of NCQA, emphasized that how care is organized and delivered matters just as much as the therapies themselves.

“We have a responsibility to use blockbuster drugs in the most effective way,” Kane said. “How we organize and deliver care matters most. If treatments are not delivered in a designed way, the full potential is not realized. The result is the opposite of value: waste.”

Trend 4: Real-Time Clinical Data Will Redefine Managed Care

Real-time clinical data is starting to reshape the health IT landscape in managed care, shared Donald Rucker, M.D., chief strategy officer at 1upHealth. While Medicare Advantage plan payments through Star Ratings have traditionally relied on claims data, plans aiming for higher scores increasingly need real-time clinical data from electronic health records (EHRs) to improve reporting and outreach, he said.

Don Rucker, M.D.

This shift requires new approaches to interoperability and data management, including clinical data acquisition, storage, analysis and API platforms to support quality performance, prior authorization, network design and care management.

“Winning plans will likely move from classic enterprise data warehouses to modern 'lakehouse' big data architectures to efficiently integrate heterogeneous data sources, test AI strategies, optimize the possibilities of FHIR and communicate with others, including via the CMS-0057 access and prior authorization APIs,” he said.

Rucker added that many payers, still focused on HEDIS Primary Source Verification (now evolving to NCQA's Electronic Clinical Data Systems), have missed chances to work more closely with in-network providers to access richer clinical data through APIs.

Trend 5: Fewer Psychiatrists Joining Insurance Networks

Ken Duckworth, M.D., medical director of NAMI, noted a shift among young psychiatric trainees who, burdened by substantial medical school debt and high housing costs, appear less concerned about joining insurance panels. With demand for their services strong, many are choosing to practice privately with patients who pay out of pocket.

Ken Duckworth, M.D.

While he clarifies that this is based on his personal observations rather than a systematic study, he believes the trend is worth attention.

“If my conversations with young psychiatrists are indicative of a larger trend, this is important information for health plans to consider when setting rates,” Duckworth said.

While the biggest topics in managed care get much attention, there are important changes happening that could have just as much impact on the future of healthcare.

Rising utilization, higher costs, the need for real-time clinical data, changes in how providers work and a stronger focus on patient-centered care all suggest that success could depend on more than just new drugs or technology.

Organizations that pay attention to these overlooked trends, and take action early, can be better prepared to deliver better care, control costs and stay competitive as the healthcare landscape continues to evolve.