Looking ahead: What the MHE 2025 State of the Industry survey tells us about 2026

The Managed Healthcare Executive 2025 State of the Industry survey is a timely snapshot of how payers, providers and pharmacy leaders are navigating today’s evolving healthcare landscape. The results highlight the pressures, opportunities and emerging shifts influencing decision-making across managed care. To add context and insights to the survey results, we invited three thought leaders to share their perspectives. You’ll find their comments interspersed in the survey results that follow.

What you’ll learn

• Key trends influencing today’s managed care landscape
• How stakeholders are responding to emerging challenges
• Actionable insights to inform strategy and decision-making

The commentators on our survey

Key takeaways

• Therapeutic cost pressures intensify, led by oncology, obesity and rare diseases.
• The biggest obstacles to adoption arehigh drug costs, formulary restrictions and reimbursement delays.
• Formulary strategies tighten with increased exclusions, step therapy expansion and preferred drug tiers.
• PBM models continue to evolve, including private-label biosimilars, narrower pharmacy networks and movement away from spread pricing.
• Biosimilars solidify their role as key cost-containment tools heading into 2026.
• Policy uncertainty grows, especially around Medicaid funding, Affordable Care Act enhanced subsidies and vaccine guidance changes
• Rising system-wide concerns include specialty drug spending, patient affordability, workforce burnout, consolidation and regulatory volatility.

Survey results

“The expanded use of antiobesity medications, especially GLP-1s [glucagon-like peptide 1s], has to be the most dramatic and meaningful development of 2025.  I anticipate that there will be greater usage in 2026 as the number of approved indications increases.  As was noted in the survey, oncology drugs will continue to place a great strain on plan resources.

"These results are consistent with what we are seeing with our clients, namely, concerns about rising care costs and utilization at the same time that access to care through affordability concerns and coverage changes driven by policy could reduce the number of enrollees in plans.

“Overall, the focus on containing costs seems to override operational concerns or developing innovative market solutions. One common theme throughout the responses to each question is how each approach (formulary, contracting, new therapy adoption, policy changes) will impact costs.” 

“Responses to questions about PBM strategies reflect a muddled outlook on the future from a pricing standpoint — both greater utilization of tools that would save purchasers money (less spread pricing, more rebate pass-through) and PBM strategies that would increase costs for purchasers (increased fees and private-label biosimilars).”

“This year’s findings show that costs are a big concern and the impact controlling those costs will have on organizations’ approach to business. This can be seen in the results showing the importance of value-based purchasing arrangements and the emphasis on formulary/benefit design changes to mitigate cost increases.”

“The significant concern about the impact of federal changes to Medicaid and the individual market is also rippling through the employer community. While the impact may be indirect, employers expect hospitals and health systems to use lost public revenue as a reason to increase prices in the commercial market.”

“Organizations will need to be flexible and respond quickly. They will need to adapt to both short-term pressures and long-term changes in the way the healthcare environment operates in the future. That includes being able to weather short- term impacts while building the infrastructure and team skills to serve the market of the future that relies on AI analysis, price and care transparency and data interoperability.” 

“I was baffled and disappointed that market consolidation was fifth among concerns about U.S. healthcare in 2026. Do the respondents realize that due to rampant horizontal and vertical consolidation by hospitals, roughly 50 cents in every dollar spent in commercial health care goes to hospitals and health systems? Many of these systems are now ‘too big to fail’ and therefore can demand incredibly high prices, driving up costs for plans, employers and consumers. The No. 1 concern — rising specialty drug costs — while a real issue, remains a tiny fraction of the costs of hospitals and their vast outpatient networks.”

“I was surprised that more respondents expect artificial intelligence (AI) to effectively reduce health care costs in 2026 than selected value-based care models. This seemed to be an expression of optimism, because the data to support the impact of AI on care costs is still nascent. The greatest opportunity for AI to impact costs, I believe, is reduction of operating expense at the plans, which savings may or may not be passed down to reduce the cost of care. I have seen a number of platforms and applications designed to reduce care costs, but I don’t believe there is sufficient evidence to say that they will be impactful in the long run. Even the best applications require a skilled clinician to validate and screen the output.”

“Attracting new members is far more expensive than retaining them, especially in Medicare Advantage. Plans should double down on improved member retention and engagement efforts. In the spirit of the old ‘secret shopper’ schemes, plans should evaluate what it is like to be a member, from enrollment, onboarding, transition of care, customer service and claims, and find out where there are opportunities for improvement.”