10 trends managed care execs shouldn’t ignore for the rest of 2026

Healthcare organizations entered 2026 facing continued financial pressure, rising specialty drug costs and growing demand for behavioral healthcare while also being pushed to modernize operations and improve access.

From prior authorization reform and AI deployment to GLP-1 management and Medicare Advantage pressure, these trends are already shaping payer and provider decision-making. Here are 10 trends managed care executives should continue watching throughout the rest of 2026.

1. Prior authorization reform pressure intensifies

Health plans continue facing pressure from physicians, regulators and patients to reduce prior authorization burden and improve access to care. In April, participating insurers reported an 11% reduction in prior authorization requirements overall, with Medicare Advantage reductions exceeding 15%.

This push increased after UnitedHealthcare announced plans to remove prior authorization requirements for 30% of currently controlled services. However, The Cigna Group said it expects more than a 70% reduction in prior authorization volume by the end of 2026.

It’s also important to note that payers aren’t ready to abandon utilization management entirely.

“The process of prior authorization is not perfect. I would even say it’s probably a little bit broken, but the survey respondents don’t seem ready to just do away with it,” Renee Rayburg, RPh., vice president of clinical strategy at PSG, said at the Asembia Specialty Pharmacy Summit 2026 in late April.

2. AI moves from experimentation into operational healthcare workflows

Healthcare organizations are shifting AI efforts away from pilot programs and toward operational deployment.

In April, Cleveland Clinic announced a $50 million AI-enabled “digital front door” initiative designed to guide patients to the appropriate site of care before they arrive at emergency departments or urgent care centers.

Industry leaders are also exploring AI for revenue cycle management, patient navigation, scheduling and care coordination. Rather than viewing AI as a standalone technology initiative, many organizations are positioning it as part of a broader operational redesign and access strategies.

Ben Scharfe, CPA, executive vice president of artificial intelligence at Altera Digital Health, told MHE that some of the biggest operational gains are occurring around the patient encounter itself, with ambient listening and summarization tools helping reduce documentation burden and allowing clinicians to spend more time focused on patient care.

Scharfe added that organizations should evaluate AI beyond direct cost savings by monitoring physician satisfaction, workflow efficiency and reductions in after-hours charting, often referred to as “pajama time.”

3. GLP-1 affordability and utilization management become more aggressive

GLP-1 medications remain one of the biggest financial pressures facing payers and employers in 2026. As costs continue rising, organizations are putting more of their focus on utilization management, adherence and return on investment rather than coverage alone.

For instance, approximately one-third of patients discontinue GLP-1 treatment within the first month and nearly two-thirds stop within three months, according to Oron Stenesh, MBA, vice president of product at Optum Rx.

Due to this, PBMs are expanding programs that combine pharmacist coaching, nutrition support, behavioral health services and digital tools aimed at improving long-term outcomes.

“Having these programs in place encourages adherence early on for people who are responding to the drug, and it helps clients get the most bang for the buck,” Stenesh told MHE in April.

However, oral GLP-1 therapies are expected to increase demand further, which could add additional pressure around affordability and long-term sustainability.

4. Medicare Advantage plans face mounting financial and regulatory pressure

Although final Medicare Advantage payment updates for 2027 came in higher than originally proposed, plans continue facing operational and regulatory pressure.

CMS delayed implementation of an updated risk-adjustment model, giving insurers additional time to prepare for changes that could affect reimbursement and coding practices. In addition, recent reports reveal that utilization management practices, supplemental benefit strategies and Star Ratings performance remain under increased scrutiny.

Plans are also balancing growing medical costs with member expectations around affordability, access and supplemental benefits.

Many insurers are expected to continue reassessing benefit design, network strategy and care management models throughout the remainder of 2026.

5. Specialty drug costs continue reshaping payer and provider strategy

Specialty pharmacy remains one of the most influential forces shaping managed care decision-making in 2026.

At the Asembia Specialty Pharmacy Summit 2026, leaders discussed strategies for managing high-cost drugs, expanding biosimilar adoption and rethinking traditional purchasing models.

Health systems such as Mayo Clinic are implementing multidisciplinary review processes to evaluate expensive therapies across clinical, operational and financial dimensions. However, other industry leaders argued that rebate-driven purchasing models continue limiting biosimilar savings opportunities.

The growing pipeline of specialty medications, cell and gene therapies and high-cost biologics is expected to keep pharmacy strategy at the center of payer and provider decision-making throughout the rest of the year.

6. Patient access and navigation strategies become more digital

More health plans and health systems are investing in digital-first models aimed at improving access, reducing unnecessary utilization and lowering costs.

For example, Blue Shield of California reported savings and reduced emergency department utilization through its Virtual Blue program, which combines virtual care with coordinated navigation services.

Organizations are also looking at digital access strategies as long-term operational investments rather than temporary pandemic-era solutions. Virtual care, AI-supported navigation and integrated scheduling systems are becoming larger components of patient engagement and care coordination efforts.

For managed care leaders, the focus is shifting from virtual care adoption alone toward measurable operational outcomes and cost reduction.

7. Behavioral healthcare access becomes an operational priority

Behavioral healthcare demand continues straining health systems nationwide, particularly among pediatric and adolescent populations.

In early May, Cleveland Clinic announced plans to expand pediatric behavioral healthcare services through a new partial hospitalization program designed for patients requiring more support than traditional outpatient therapy but not inpatient hospitalization.

Healthcare organizations continue searching for ways to address rising rates of anxiety, depression and suicide-related concerns while reducing emergency department overcrowding and inpatient capacity strain.

Behavioral healthcare expansion is increasingly becoming both a clinical priority and an operational necessity for health systems and payers.

8. Alternative pharmacy purchasing and rebate models gain traction

Pressure surrounding drug pricing transparency and affordability is driving interest in alternative purchasing models across healthcare.

Further at Asembia, even more industry leaders discussed growing interest in direct-to-patient, direct-to-employer and cash-based purchasing approaches designed to bypass traditional pricing and rebate structures.

Additionally, MHE reported in April that Cigna announced its rebate-free Evernorth Signature Pharmacy Benefits Services model would become the standard approach for clients by 2028.

These developments suggest healthcare organizations are more than open to reconsider traditional PBM structures, rebate strategies and pharmacy purchasing models in response to employer and payer pressure.

9. Value-based care strategies become more pharmacy driven

Pharmacy teams are playing larger roles in value-based care arrangements, particularly for high-risk and high-cost patient populations.

In another discussion at Asembia, presenters from UMass Memorial Health and Shields Health Solutions discussed how specialty pharmacy programs are expanding beyond medication management to include care coordination, lifestyle counseling and social determinants of health support. As a result, these efforts are improving health outcomes and supporting shared savings in value-based care.

As specialty medication utilization continues growing, pharmacy teams are increasingly becoming central participants in population health management and cost-control strategies tied to value-based reimbursement models.

10. Healthcare organizations prepare for greater policy uncertainty heading into 2027

Although organizations remain focused on operational performance in 2026, many healthcare leaders are also preparing for continued policy uncertainty surrounding Medicare Advantage, Medicaid, ACA markets and drug pricing.

Recent developments involving prior authorization reform, exchange market participation, risk-adjustment changes and pharmacy benefit redesign suggest organizations may need to remain flexible as reimbursement and regulatory expectations continue evolving.

For many payer and provider executives, the focus is shifting from short-term recovery toward building operational flexibility amid continued reimbursement, regulatory and pharmacy market uncertainty.