The State of Managed Care in 2026: Execution Is the Differentiator
Managed care organizations are navigating an increasingly complex environment.
Rising healthcare costs, changing Medicaid enrollment, regulatory shifts, access challenges and evolving member expectations are converging at the same time. For health plans, the challenge isn’t simply understanding what’s changing. It’s having the operational capacity to respond.
That was a central theme in a recent Soaring to New Health conversation with Victor Fields, President and CEO of Highmark Wholecare, and Joe Glinka, Director, Pennsylvania HealthChoices.
Their message for managed care leaders was clear: strategy matters, but execution is becoming the differentiator.
Complexity Is Becoming an Operational Challenge
Policy, funding and market changes don’t happen in isolation.
A change in eligibility can affect enrollment, member communications and care management. Rising pharmacy and medical costs create additional financial pressure. New regulatory requirements introduce technology, data, staffing and implementation needs.
At the same time, health plans are being held to increasingly high expectations around quality, access and member experience.
That means organizations need more than a strong strategy. They need the people, processes, technology and data to turn that strategy into action.
Access Starts with Understanding the Member
Access remains one of the clearest examples of the gap between strategy and operational reality.
Highmark Wholecare serves 27 Pennsylvania counties, 16 of which are considered rural. For members in those communities, accessing care can involve provider availability, transportation, distance and other challenges that extend well beyond the health plan itself.
Those barriers become even more complex for Medicaid and Dual Eligible Special Needs Plan populations.
Fields described the importance of approaching member experience through the “Platinum Rule”: treat others the way they want to be treated.
For health plans, that means understanding what members actually need and designing operations around those realities.
Data can help identify risk and opportunity, but Fields emphasized another critical distinction: outreach isn’t the same as engagement.
High-performing organizations don’t stop at measuring whether they contacted a member. They determine whether the member actually engaged and whether the communication loop was closed.
Operational Readiness Has to Keep Pace with Change
Growth and change both require capacity.
Fields have framed that capacity around four areas: people, process, technology and data.
The strongest organizations aren’t building solely for today’s needs. They’re anticipating what may be required next.
That becomes particularly important as policy changes move toward implementation. Regulatory requirements can trigger changes across eligibility, workflows, technology, data exchange, staffing and member communications and those changes can’t always be operationalized overnight.
Organizations don’t necessarily need every regulatory detail finalized before they begin preparing.
They can assess potential impacts, identify dependencies, evaluate capacity and determine where implementation risk may exist.
That readiness creates flexibility when requirements become clearer.
Technology Should Create More Capacity for Human Connection
Technology and AI will play an increasingly important role in managed care.
Predictive analytics can help organizations identify emerging risk. Automation can reduce administrative burden. Digital tools can improve member communications. Technologies such as ambient listening may give care managers more time to focus on care instead of documentation.
But technology alone isn’t the end goal.
As Fields noted, managed care must remain a human business.
The opportunity is to use technology to create capacity for better engagement, not simply replace human interaction.
That balance may become increasingly important as health plans look for ways to operate more efficiently while improving member experience.
Execution Is the Differentiator
Managed care organizations can’t control every policy change, funding decision or market shift.
They can control how prepared they are to respond.
That means investing in capacity before it becomes a constraint, understanding members before designing solutions, connecting policy decisions to operational requirements and building organizations that can adapt when conditions change.
The organizations that thrive won’t necessarily be those that predict every change.
They’ll be the ones prepared to execute when change arrives.
Listen to the full Soaring to New Health conversation with Victor Fields and Joe Glinka for more perspectives on the state of managed care and what leaders should be preparing for next: Soaring to New Health
