As the healthcare industry approaches 2026, payor economics are evolving in response to rising costs and increasing demands for measurable value. A recent Medical Economics article highlights that payors are redefining how performance and efficiency are evaluated. Specifically, they are moving further away from volume-based reimbursement. This shift presents significant challenges for providers. For example, there is increased pressure to demonstrate value, limited visibility into true contract and payor economics, and growing financial risk tied to quality performance and risk adjustment accuracy.

To succeed in this changing landscape, providers must better understand contract economics and translate clinical outcomes into financial impact. In addition, they must take a proactive, data-driven approach to payor negotiations. The article outlines five strategic imperatives to help providers protect margins and remain competitive

1. Know your economics, contract by contract: Understand margin by product line, geography, and service type. If payors are modeling your data more precisely than you are, that’s a risk

How Ensure helps:

• ENSUREFIN©: Enhanced financial capabilities, drill down analytics down to patient level P&L, with patient attribution to do PCP-level P&L. Also, costs/utilization trending, the same way payers analyze their cost/utilization trends. This was developed by Payers Executives. Users can create P&L views by LOB, by product, by geography, cost category, by payer

2. Frame your performance in economic terms: Don’t just report on quality. Show the impact of your model on Stars, risk scores, and total cost of care. Tie your story to outcomes that affect payor margin.

How Ensure helps:

• ENSUREQUAL©: Our quality management platform helps payers and provider organizations improve quality measure performance through tools like SNP HRA surveys, HRSN assessments, and other clinician-assessed and patient-reported outcomes. It enables efficient data capture, automated scoring, and clinical intervention tracking. Moreover, it also monitors progress toward achieving 100% compliance on each measure and supports high Total Quality Scores (TQS).
• ENSURESTARS©: This solution provides a full Medicare Advantage STARS dashboard, including a Star measure performance trending, Star rating optimizer, and Star rating scenario planning for Medicare Advantage health plans.
• ENSURERS©: The risk adjustment management module helps with the identification of suspected clinical conditions. It also allows users to track documented and undocumented clinical conditions for these suspects, as well as re-document clinical conditions from prior periods for existing patients.

3. Plan renewals with offensive strategy: Don’t wait for the payor to set the pace. Run benchmarks, assess escalators, model scenarios. If you’re not driving the timeline, you’re reacting to it.

How Ensure helps:

• ENSURERS©: End-to-End risk adjustment solution for suspect identification, risk score calculation & projection, AI-powered clinical documentation review for missed coding opportunities, and RADV findings risk mitigation.
• ENSUREQUAL©: Ability to view quality measures performance, including Stars measures providers can impact based on EMR data and payers’ data. They can also compare both.

4. Push for shared risk where you can control outcomes: Don’t absorb risk for services where you don’t have the ability, the market share, and the clinical expertise supported by technology. Alternatively, if you can improve cost, coding, or Stars, show the payor the math and claim a share of the upside. You might just have to be willing to terminate over it.

How Ensure helps:

• ENSUREXPERTS©: By fostering strategic partnerships with influential community primary care physicians (PCPs), we can support the formation of PCP IPAs/MSOs. This, coupled with our back-office MSO-like services
• ENSURECM©: The platform enables comprehensive patient engagement by tracking and monitoring patient interactions and adherence. It also defines and manages high-performance referral networks, supports effective care coordination and disease management, and facilitates seamless collaboration with disease-specific interdisciplinary care teams.

5. Be ready for conflict: Some negotiations will require a termination notice and then a public dispute. Have the PR plan, legal strategy, and operational response mapped in advance. Public disputes are now more important than ever to obtain increases above inflation.

How Ensure helps:

• ENSUREXPERTS©: By fostering strategic partnerships with influential community primary care physicians (PCPs), we can support the formation of PCP IPAs/MSOs. This, coupled with our back-office MSO-like services.

With Ensure, providers can not only survive the evolving payor environment but thrive. They can do so by leveraging analytics, operational expertise, and targeted strategies to maximize value, mitigate risk, and drive better outcomes for both patients and their organizations.

Contact us today!

https://www.medicaleconomics.com/view/what-comes-next-how-providers-can-prepare-for-the-next-era-of-payor-economics-in-2026