The Executive Suite: 2026

Monday, January 26, 2026

Prediction: 2026 is the year affordability rewrites patient behavior and health system margins

The past few years have tested health systems, but 2026 will bring an affordability shock that will alter patient behavior and health system margins dramatically. As enhanced ACA subsidies expire, Medicaid eligibility becomes more stringent, and employer-sponsored premiums reach their highest levels in over a decade, millions of Americans will transition from being insured to being un- or underinsured. The financial and clinical fallout will be immediate, and visible by the end of January as CFOs see the first signs of a measurable revenue gap.

For physicians, this shift will manifest in exam rooms, missed visits, and delayed presentations that spill over into emergency care. For health systems, it will surface as shrinking reimbursement, rising bad debt, and care deterioration tied to affordability rather than clinical need. The question is no longer whether affordability pressure will escalate, but how prepared systems are to absorb it once traditional assumptions about coverage begin to break down in Q1.

A national affordability shock arrives

The first months of 2026 will reveal instability across all payer categories. ACA marketplace enrollees will face steep premium increases as federal subsidies are set to expire. Many will fall behind on payments or drop coverage altogether. Medicaid redeterminations will continue removing eligible patients for procedural reasons unrelated to income or employment.

Even the employer market, long regarded as the most stable segment, will not be spared. Employer health plan costs are projected to increase, alongside rising deductibles. Many families will begin to feel the affordability shock in January and February, when they attempt to use their insurance during peak flu season and encounter dramatically higher out-of-pocket expense.

The IRS has already set the 2026 out-of-pocket maximum for high-deductible health plans at $17,400 for a family of four. That alone will push many insured patients into “functional underinsurance,” where care is technically covered but effectively unaffordable.

These pressures will lead to predictable behavioral shifts, including deferred primary care, postponed elective procedures, skipped tests, and inconsistent adherence to medication.

The financial breakpoint for health systems

By mid-year, affordability-driven stress will create measurable revenue pressure, likely resulting in a 3–4% revenue gap as three key forces converge:

Delayed elective procedures among high-deductible plan members
Faster bad-debt growth as patient liabilities climb
Coverage churn leading to eligibility denials and preventable write-offs

Systems with large Medicaid and ACA populations will feel the sharpest strain. All organizations will face more complex conditions, driven by affordability rather than access barriers. For physicians, this will mean more unmanaged chronic conditions, higher acuity at presentation, and patients making care decisions based on cost rather than medical need.

Emergency departments become the default access point

Families priced out of upstream care will rely on emergency departments (EDs), not because EDs are convenient, but because they are the only care setting where cost cannot be used as a barrier to entry. Volume will rise, acuity will rise, and reimbursement will fall. We witnessed early signs of this behavior post-pandemic. While overall ED visits declined in early 2020, by 2021-2022, many systems experienced rising acuity, crowding, and crowding as delayed care turned into urgent needs; 2026 will accelerate this trend.

Without intervention, many EDs will become the de facto primary care home for patients who can no longer afford traditional access points, an early indicator of affordability stress.

Patient financial access becomes a core capability

To avoid major revenue disruption in 2026, health systems must proactively treat patient financial access as a primary operational focus. Provide financial clarity early and address patients’ financial status before balance issues occur. This can be done via:

Implementing real-time segmentation tools to identify patients’ insurance and financial status
Offering simple financing options and early cost estimates to lower no-show rates and limit bad debt
Guiding patients through renewals, subsidy checks, and premium support applications
Connecting patients with foundation aid and manufacturer programs for high-cost therapies
Adopting transparent digital tools for financial interactions that meet patient expectations

What physicians should expect, and how to prepare

Physicians will feel the affordability crisis as premiums rise and subsidies fall, more insured and underinsured patients delay care, skip visits, and ration medications. Expect worsening chronic disease control, heavier ED reliance, and greater clinical complexity. Financial strain shapes clinical outcomes, so physicians advocating for stronger financial-access programs will help preserve continuity of care.

The year ahead will test the resilience of care teams and the strength of patient relationships. Systems will begin having enough data to shift from “wait and see” to restructuring their entire financial access strategy. Organizations that treat financial access as part of the care experience will be far better equipped to protect access and affordability for patients, stabilize margins, and support the communities they serve.

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Thursday, January 22, 2026

5 ways to talk about affordability with patients before they get to the pharmacy

The cost of prescriptions often forces patients to make difficult choices. Our research shows that one out of five Americans say they stop taking their medications or take fewer doses than prescribed when finances are tight, making discussions about finances a critical part of patient care.

It’s heartbreaking when a patient returns to your office or arrives at the emergency department in worse shape than when you last saw them. When that happens, it’s often because the patient doesn’t have the financial means to fill crucial prescriptions.

It is far easier—and impactful—to have open and transparent discussions with patients in the moment of care when you can discuss options and access additional resources in the clinic setting. Trying to handle these issues hours or days later, in the dead of night, or worse, not at all, can lead to adverse events.

Here are five actionable tips for navigating these sensitive conversations:

1. Initiate the money conversation early

Bring up affordability as early as possible. Being upfront about costs fosters trust and reduces the likelihood that patients will avoid treatment altogether.

There’s a direct link between a patient’s financial ability and adherence to treatment plans. By regularly asking about affordability, you’re not only addressing immediate barriers but also ensuring long-term treatment success.

Conversation prompt: "This is the treatment I think is best in your situation, but I realize it might not be affordable. I do have some other options we could consider if you’d like to go over them.”

2. Ask everyone—no assumptions

Economic vulnerability isn’t always visible. Patients who seemed financially stable last year may be struggling this year. In a volatile economy, no one is immune to sudden financial changes. Get in the habit of asking all patients about their ability to afford care and never assume they’ll speak up on their own.

Conversation prompt: "I ask every patient in my practice whether treatment affordability may impact the decision to start/continue treatment. Is there anything I can do to help you with any hesitations you have about the cost or impact of the therapy?”

3. Offer to review benefit coverage

Understanding the nuances of insurance plans can be overwhelming, even for the most informed patients. Don’t assume they understand coverage details, co-pays, co-insurance, prior authorizations, or the difference between medical and RX benefits. Sometimes, simply clarifying what’s covered can make all the difference in a patient’s decision to proceed with treatment.

Conversation prompt: "Do you have questions about how much of the cost your insurance will cover?" (Then, assist them in navigating any potential barriers.)

4. Stay up to date onpatient assistance programs and other resources for affordability

Pharmaceutical companies often offer patient assistance programs that provide significant relief. Keep track of those most frequently used in your practice and support patients through the prior authorization process.

Conversation prompt: "There may be a patient assistance program available from the manufacturer of this drug. There are certain criteria required to qualify for the program. Would it be helpful to review those with you?”

5. Discuss financing opportunities

Some private practices, particularly those offering treatments not fully covered (or not covered at all) by medical, prescription, or dental benefits, offer payment plans and other financing options to make therapy more affordable.

When patients know there’s flexibility in payment, it eases the stress of managing large bills. Bringing up financing options, whether through a third-party solution or an in-house payment plan, can make treatment more accessible, encouraging patients to move forward without fear of immediate financial strain.

Conversation prompt: "Did you know you can apply for financing options if your health insurance benefits don’t cover this treatment?"

Discussing affordability is essential to patient-centered care, especially in today’s tough financial climate. When we have open conversations about cost, we can ease the pressure on patients and help them get the care they need as quickly as possible.

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Tuesday, January 20, 2026

Rethinking HEDIS and Stars: Building a quality-first culture

HEDIS measures and Stars Ratings are central to how US health plans evaluate and incentivize care quality. They measure performance and create financial incentives that encourage proactive detection and management of conditions, while adding operational complexity for providers contracted with those plans.

However, these are not straightforward, check-the-box programs, and organizations often struggle to balance population health efforts while maintaining compliance and quality care. Here are some common challenges involved with launching HEDIS and Stars initiatives, along with practical strategies to shift from a compliance-driven mindset to a quality-first culture.

Shifting internal mindsets from compliance to quality culture

My former mentor once told me, "As long as you do what's right for the patient, the money will follow."

That advice still holds, but only if doing what’s right is paired with accurate documentation and coding. In value-based care, high performance depends not just on providing quality care but on capturing it in the data. When a service isn’t coded correctly or falls outside a measure’s timeframe, it won’t count, even if the care itself was excellent.

When compliance dictates actions that don't make sense or fail to account for the ramifications for your patients, that’s when you encounter problems. In those cases, organizations need to revisit how their processes serve both goals. It’s also essential to educate and simplify things for providers, as they might not be familiar with all the compliance requirements for every health plan and contract. It’s necessary to train the entire organization to understand why mammograms, colonoscopies, and other quality measures are essential and why we're asking them to implement them.

Building this shared understanding is essential, especially since Star Ratings bonuses go to health plans and only reach providers through their contractual arrangements. When clinicians see how these measures ultimately tie back to better patient care and organizational sustainability, compliance becomes a by-product of quality—not the other way around.

Addressing care gaps year-round

HEDIS, Stars, and other quality programs require an annual strategy. Gap closure should be designed for continuous, year-round data capture and real-time closure at the point of care, rather than end-of-year chart abstraction alone.

If a contract isn't performing or the assigned healthcare provider can’t reach all of their patients, you can bring in what I like to call a “striker team.” That team would be pulled off regular daily activities to help the provider be laser-focused. It could take a week or more, but all the information on all the patients would be sent to the payers.

That’s what I call short-term gap closure: periods when you need an all-hands-on-deck push to complete outreach or documentation before reporting deadlines. These surge efforts are valuable, but they also need to be balanced with sustained, long-term strategies for year-round gap management. Some gaps can be resolved through administrative workflows, like scheduling or record retrieval, while others require clinical review and judgment. The key is to clearly define which responsibilities belong to each team, so both administrative and clinical staff can work efficiently without overlap or burnout.

Streamlining contract complexities

When I first started getting involved in HEDIS and Stars, I had 15 different contracts. Every single one was completely different. I went from never having to report on any of it (because I wasn't in any value-based contracts) to needing to be aware of 70 other measures.

Eventually, I became savvy enough to learn that I could leverage my influence with payers. Even though the measures themselves are defined and scored outside your organization, you can still work with payers to focus your contracts on a common, manageable set that your infrastructure can reliably support. Aligning incentive sets this way helps reduce confusion, concentrate effort, and make meaningful improvement achievable across all agreements.

Normalizing data

Managing unwieldy healthcare data is a significant challenge in value-based care. We all know that data is often siloed across departments and in various formats. That’s why a centralized location at each provider group, where their data is normalized, is critical.

Organizations must either build their own data warehouses to store all this information internally or work with a third-party provider to manage it. If you can normalize your information and then serve it back to the various departments that need it, everybody will pull from the same central repository, allowing them to take action with all of this rich data. Keeping auditability in mind, make sure that all data feeding quality reporting is validated, traceable, and consistent across systems.

Engaging physicians through a patient-first approach

Ultimately, healthcare providers are more concerned with the clinical aspects of their work. They are committed to keeping their patients healthy. And until every single administrator adopts the mindset of doing what's right by patients, providers will view value-based care through programs like HEDIS and Stars as an administrative burden.

The goal isn’t to choose between quality and compliance, but to have them reinforce each other, using compliance measures to document and scale the quality care clinicians already provide. When organizations approach compliance this way, they can close care gaps more effectively, streamline contracts, and normalize data to make these programs run smoothly and successfully.

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Thursday, January 15, 2026

A true story of payer negotiations

Payer negotiations are like David confronting Goliath. Physicians, whether in small practices or employed by hospitals, face a daunting challenge when trying to get a payer to approve a medication, procedure or imaging study. It is not possible to negotiate approval with every payer; however, you can pick those that are most egregious, delinquent in payment or not compensating for services performed that deserve compensation.

Let me share one success story demonstrating how to navigate the negotiation process. I was an early adopter of a minimally invasive procedure for treating benign prostatic hyperplasia. The standard of care was hospital admission and surgical ablation of the obstruction to urine flow. The cost of the hospital procedure was $25,000 to $35,000. The patient was in the hospital for two to three days, wore a catheter for another five to seven days, and resumed normal activities, lifting heavy objects, sports and sexual activity in four to six weeks. The minimally invasive procedure, or UroLift, was done in the office under local anesthesia, and the patient had a catheter for a day or less. The patient could resume all normal activities in 10 to 14 days. When patients were given the option of hospitalization and surgery versus an office procedure, 100% opted for the minimally invasive procedure.

First, I found the decision maker (bean counter) with some effort. I explained the minimally invasive procedure’s economics, patient preference and outcomes. I sent them articles from the medical literature that confirmed the office procedure had outcomes equivalent to the surgical procedure. I also informed them that a code was available for the minimally invasive procedure. I also submitted testimonials from several patients who supported the minimally invasive procedure. After several months of discussions, I received appropriate compensation for the procedure.

My takeaway message is that confronting the health care payment process can be daunting. But remember, sometimes the Davids really do beat the Goliaths!

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Monday, January 12, 2026

How 831(b) plans can protect your practice from unexpected, uninsured costs

After five consecutive years of cuts, Medicare physicians can finally expect to see higher revenues in 2026. Following the passing of the One Big Beautiful Bill Act in July, Medicare physicians will observe a one-year 2.5% payment increase for 2026. This comes in addition to the reversal of a 2.83% pay cut and the temporary 2% payment increase that was applied through December 2025.

This news is welcome to practitioners who receive Medicare payments and have been impacted by inflation and other rising costs.

With higher revenues forecasted for 2026, practices should consider saving those extra funds to cover unexpected, uninsurable costs, including denied claims, reimbursement rate cuts and changes in government policies.

One way to do so is to make contributions to an 831(b) plan. This risk management tool was created by Congress in 1986 and allows businesses to set aside tax-deferred reserves to offset the impact of uninsured events, including earnings loss, government orders, business disruptions and more.

Physicians using 831(b) plans can gain peace of mind knowing they aren’t at the mercy of traditional insurers, and they can focus on what’s most important: delivering quality care to their patients.

Private practices should explore connecting with an 831(b) plan administrator who specializes in setting up and managing self-insurance options for small businesses. By leveraging 831(b) plans, plan administrators work alongside business owners to craft customized self-insurance plans that work for them and their specific needs.

One of our private practice clients shares that their 831(b) plan has complemented the recent changes to the Medicare payment structure, saying their plan “will allow their practice to stay solvent so they can continue to provide critically needed care to rural and underserved communities.”

Another example of how 831(b) plans are helping our clients stay resilient involves a national consulting firm specializing in business management services that relies heavily on government infrastructure funding for substantial portions of their revenue.

When a sudden change in public policy abruptly terminated one of their government funding streams, the firm realized it would be on the hook to remedy the loss, estimated to be about $2 million. Traditional insurance policies typically exclude losses resulting from political decisions or governmental policy shifts, leaving businesses highly vulnerable to sudden financial disruptions stemming from political actions.

The firm quickly filed a claim under SRA’s political risk policy within their 831(b) plan, and the policy provided coverage up to a limit of $600,000, significantly mitigating the financial damage incurred by the company. This immediate financial support enabled the firm to continue operations and stabilize its financial position during a critical transition period.

These are just a few examples of how 831(b) plans can keep all types of small businesses moving forward after unexpected incidents.

In the constantly evolving landscape of health care, insurance and public policy, medical professionals should have more agency when it comes to protecting and preparing their practices from the unknown. An 831(b) plan shifts that power from the insurer to the insured — back into the hands of the practice owner who leads the company, the way it is intended.

As the mainstream insurance industry remains volatile, it is up to every business leader to take the appropriate action to protect themselves, their companies, their employees and their clients. This means addressing the gaps where mainstream insurance providers fall short. Being able to self-insure can protect your practice from underinsured or uninsured unplanned events.

Doing so starts with a comprehensive, effective and affordable risk management strategy where they have the authority and ability to respond to immediate needs and impending crises. A customized 831(b) plan can help make that a reality.

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Wednesday, January 7, 2026

Group coaching cuts physician burnout nearly 30% in UCLA study

A randomized clinical trial at the University of California, Los Angeles (UCLA) suggests that small group coaching could be a practical way to tackle physician burnout — without breaking the bank. Researchers found that six virtual sessions, held in groups of three doctors per coach, reduced burnout by nearly 30% among internal medicine faculty. That’s more than double the reduction seen with traditional one-on-one coaching, which is typically more expensive and harder to scale.

The findings were published July 11 in the Journal of General Internal Medicine.

Led by Joshua Khalili, M.D. — who is director of physician wellness in the UCLA Department of Medicine and an assistant clinical professor of medicine at the David Geffen School of Medicine at UCLA — the randomized trial divided 79 attending physicians into three groups, with one receiving individual coaching, another receiving small group coaching and the third serving as a control group.

All coaching took place over Zoom and followed a structured program that focused on building self-awareness, setting goals and navigating workplace stress.

Participants in the small group coaching arm saw their burnout rate drop by 29.6%. The one-on-one group saw a 13.4% decrease. In the control group, burnout actually increased by 11.1% during the study period.

“This new, small-group model of professional coaching can make a significant impact in physician burnout and costs much less than the one-on-one model,” Khalili said.

Lasting effects and lower cost

Even six months after coaching ended, burnout levels stayed down for those in the small group program and continued to improve in the one-on-one group. The format — brief, virtual and focused — proved convenient enough for busy physicians to complete. Nearly all participants finished their sessions.

The price point is also a potential game-changer. Small group coaching cost $400 per physician, less than half the $1,000 price tag for one-on-one coaching. Researchers also noted benefits beyond burnout: small group participants reported feeling more in control of their workload, and individual coaching seemed to boost work-related energy.

With more than half of U.S. physicians experiencing some level of burnout and an estimated $4.6 billion in systemwide costs each year, Khalili and his colleagues say the time is ripe for broader adoption.

A model worth replicating

Notably, the small group coaching participants began with higher levels of burnout than those in the one-on-one cohort but still saw comparable relative improvements.

“By improving physicians’ well-being, engagement and sense of support, interventions like coaching can enhance the quality of care patients receive, making this a public health priority, not just a workplace issue,” Khalili said.

The coaching program is now being offered to physicians in UCLA’s Department of Medicine. Khalili and his team are encouraging other health systems to explore group-based coaching and are calling for additional studies to confirm the results across different practice environments.

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Monday, January 5, 2026

Seven steps to boost cash flow for your health care practice

Successfully managing cash flow is a primary concern for physicians as they monitor the financial wellbeing of their practice. Healthy cash flow contributes to peace of mind, supports smooth business operations, allows for expansion of services and technology, and ultimately has a positive impact on patient care. The financial health of a practice revolves around claims management. Yet with an estimated average of 15% of private payer claims denied on the first pass — and close to 17% denied for Medicare claims — practices are at risk for cash flow disruption.

In this environment, it's imperative for physicians to place a heavy emphasis on claims submissions, putting processes in place to maximize first-time clean claims.

Common reasons for claims denial and how to address them

In general, claims are typically denied due to inaccurate or missing information. This can trace back to the patient record itself, information entered during the patient encounter, or coding errors. In addition, workflows and processes the practice follows (or lacks) when it comes to claims submissions and timely follow up also contribute to claims denials.

Below are seven primary reasons that claims are denied, along with steps practices can take to avoid them:

Diagnosis mismatch to CPTs billed. This occurs when a diagnosis, the ICD code, submitted on the claim does not support the procedure or service that was billed to the insurance company. In most cases, this results from a data entry error.

Solution: Stay up to date on the latest coding protocols, and ensure data entry is clean and correct before a claim is submitted. Consider leveraging newly released AI features that may be available in your EHR. eClinicalWorks V12.0.3, for example, includes an AI assistant that can notify the physician or other clinicians involved in patient care of suspected coding errors.

Insurance rules for claim coding not followed. Insurance companies may implement specific billing guidelines that practices must adhere to when submitting a claim. Many have requirements for prior authorization, specific documentation, or specific codes for services.

Solution: Ensure that billing staff are trained on current requirements from common payers. This could involve a review of past denials and standardizing claims submission procedures for each payer based on corrected and clean claims. Or leverage your EHR to automate this function, creating rules for identifying and correcting claims before submission.

Missing referral from primary care physician. This can be confusing to navigate, as not all insurance companies require a referral to a specialist. Plus, requirements may not be consistent in terms of which specialists require a referral or not.

Solution: To avoid the risk of not receiving payment, some practices make it a rule to always require a referral. While this seems a logical stop-gap, it results in extra paperwork for the practice and headache for the patient. The better route is to rely on your EHR. Leading EHRs can prompt the physician whether a referral is needed through decision support systems, algorithms, pre-defined rules and alerts based on the patient data that’s entered into the system.

Credentialing. In order to successfully submit a claim to a payer, the physicians and other clinicians must be credentialed to ensure they meet the standards to provide care and are eligible to receive reimbursement. Without proper credentialing, claims will be denied with payments delayed.

Solution: Rely on your EHR to support the credentialing process. Most EHRs include features to automate credentialing application submission, monitor for re-credentialing timelines, and integrate with clearinghouses to streamline the process.

Lack of insurance verification. Without proper verification of a patient’s most current insurance coverage, the practice is at risk of a denied claim. A patient may have changed or terminated insurance providers leading you to bill the wrong company. A change in the patient’s coverage may also impact whether a service is eligible for reimbursement. Or a patient may have fallen behind on premiums causing insurance to lapse and resulting in a denial.

Solution: Insurance must be verified upon booking and admission for every patient. This helps ensure insurance payment for services to the practice and clarifies responsibility for the patient to avoid unexpected bills. Major EHR systems have features to automate this process, including real-time eligibility checks and integration with payer systems. If you don’t already leverage this functionality, explore the technical aspects of implementing it into your practice, along with the workflows required for successful rollout and execution.

Timely management of denied claims. Each insurance company has a very specific window of time for a practice to resubmit a denied claim. While this timeframe varies, denied claims may generally be resubmitted within six months of the original denial. Many practices lose track of denied claims (especially when they are dealing with a significant volume), which means payment for services will never be received.

Solution: Your EHR contains the power to create rules, gain visibility through financial dashboards, and set alerts for this important function. This can help keep track of denied claims and correct the errors for successful resubmission. As you work through this process, you’ll start to uncover trends in why claims are being denied. This will help you develop new procedures to avoid it on future claims. Some practices do not rework and resubmit denied claims altogether, often due to staffing strain. Always make this a priority. Remember, the goal is to minimize denied claims and reach a 90% or higher first-pass clean claims rate.

Ineffective workflows for billing and follow up. Practices experiencing a higher-than-normal denial rate typically have improper workflows for billing, which also means that following up on denied claims is difficult. That’s because of challenges accessing the necessary information to pinpoint the problem, leading to payment delays and lack of insight into the finances of the practice.

Solution: Solid workflows are critical to the financial success of your practice. They guide how your EHR is used for billing and practice management, which is responsible for key tasks, goals, and expectations for your operations. Consider the process from start to finish, beginning with the patient check-in and encounter with the physician through insurance verification, coding, and claims submission. Discover how your EHR can automate manual processes to avoid mistakes, and create a system of checks and balances to help ensure clean claims submission.

Ultimately, with these seven recommendations for RCM processes and an EHR that’s configured for financial success, practices can improve claims success rates and ensure timely payment for services rendered.