Insight to Action: Orchestrating Healthcare Affordability

Lori Logan, NASCO President and CEO

Today’s healthcare affordability crisis is testing health plans in ways few anticipated. Yet, while the pressure is acute, it also creates a defining moment: a chance to meet the competitive mandate for transformation. As both administrative and medical costs continue to rise, it is increasingly clear that incremental, siloed cost-containment efforts are no longer sufficient. What is required instead is structural change, namely, an enterprise-wide shift that enables health plans to orchestrate affordability across systems, stakeholders, and channels.

At the same time, many health plans remain constrained by legacy core operating systems designed for a different era, focused on claims processing and volume-based economics. These systems, while foundational, do not support the flexibility, responsiveness, and insight-driven decision-making now required. As a result, health plans must evolve toward operating models and systems that are dynamic, data-informed, and capable of coordinating multiple variables across an increasingly complex ecosystem.

Against this backdrop, leading organizations are beginning to embrace a new role: that of the affordability orchestrator. However, this transition does not happen organically. It requires deliberate focus and disciplined execution. Broadly, three steps can help guide this transformation.

1. Orchestrating Affordability: Set the Strategy

To begin with, transformation must be anchored in a clear, insight-driven strategy that is supported by advanced analytics, modeling, and scenario planning. Without this foundation, even well-intentioned initiatives risk missing their mark.

At the center of this effort is a critical question: does your organization truly understand where the greatest opportunities exist to reduce medical costs?

From there, several related considerations emerge. For example, how are costs distributed between claim-based and non-claim-based benefits? In an environment defined by multi-level attribution, can you map all the care innovations and network programs to which your members are attributed? Furthermore, how do condition-based programs interact with broader network strategies, particularly when segmented across distinct population cohorts? Equally important is the ability to identify which programs are simultaneously improving cost, quality, and member experience, and, just as critically, how to guide members toward those high-value pathways. If these answers are not readily available at scale, it signals a need for greater investment in analytics to inform network strategy.

2. Orchestrating Affordability: Identify Capability Gaps

With strategy defined, the next step is to assess whether the organization’s capabilities can support it. To orchestrate affordability effectively, health plans need a flexible core chassis that can seamlessly integrate claim and non-claim benefits, adjudicate complex scenarios, and account for member attribution across overlapping programs. For instance, the system should be able to recognize when a member is attributed to a value-based care arrangement within a broader capitated model and track the encounter in the total cost of care.

This raises a set of fundamental questions. Does a plan have insight into the base performance of their full medical cost to inform innovation and also the current network, product, and experience capabilities to enable mass customization and speed-to-market? How quickly are new products configured, tested, and brought to market?

Where gaps exist, investments become essential. On the network side, this may include enhancing network capabilities that increase flexibility and provider enablement. On the product side, it may involve pre-packaged product components and commercialized connectors.

3. Orchestrating Affordability: Prioritize Investments

Finally, transformation requires disciplined investment prioritization. Given finite resources, health plans must be intentional about where and how they allocate capital, ensuring that investments address both administrative efficiency and medical cost performance.

Plans need to prioritize reducing administrative costs while also lowering the total cost of care. A key question to guide this process is whether investment decisions are meaningfully impacting medical economics. In other words, are you not only influencing who pays and how much, but also addressing the underlying cost of the care itself?

Moreover, leading organizations are adopting a dual-track approach that simultaneously optimizes current performance while building the capabilities required for future-state orchestration. In this context, sequencing matters. Investments should be staged in a way that delivers near-term value while enabling longer-term transformation.

Ultimately, the path forward is neither simple nor linear. However, health plans that take a thoughtful approach that is grounded in strategy, informed by capability assessment, and executed through disciplined investment, are better positioned to navigate both the challenges and opportunities of the affordability crisis.

Those that succeed will do more than manage costs. They will redefine their role in the healthcare ecosystem, creating durable competitive advantage by orchestrating affordability.

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To read the first blog in the series, From Healthcare Affordability Crisis to Transformation, Now, click here.