2024 Trends and 2025 Predictions: Insights From Health Care Leaders on Advancing Medicare, AI Solutions, and Clinical Data Utilization
In this exclusive commentary for First Report Managed Care, health experts and business leaders explore how advancements in Medicare Advantage, ambient intelligence, generative AI, cybersecurity, risk adjustment, precision oncology, and AI integration are reshaping the health care landscape, highlighting the pivotal trends and innovations expected to define 2025.
“2024 will be remembered for increased scrutiny of Medicare Advantage. Centers for Medicare and Medicaid Services (CMS) has the task of regulating plans' desire to increase profits by ‘doing less’ with the requirement that they provide care (comparable to classic fee-for-service Medicare). CMS manages this moral hazard with complex rules on marketing, risk scoring, prior authorization, and network adequacy, but ‘ground zero’ for this inherent tension is with Star Ratings and their disproportionate impact on payment. Widespread Star ratings declines have led to turmoil in the C-suite after large share price drops. Multiple Medicare Advantage plans are currently suing the federal government over their ratings.
What happens in 2025? Successful plans will totally revamp their IT infrastructure to become far more capable in managing the clinical data needed to successfully manage care. The era of relying solely on claims data to control plan spending and ratings is ending. The need to ‘get clinical’ will likely also extend to managed Medicaid, which has so far been buffered by individual state policies.”
—Dr Don Rucker, chief strategy officer, 1upHealth
“In 2024, health care organizations took initial steps to deploy ambient technology and smart room solutions to enhance workforce productivity, such as ambient documentation, virtual nursing, and fall prediction systems. Looking ahead to 2025, we’ll see expanded acceptance and implementation of ambient intelligence capabilities in both inpatient and ambulatory settings.
The focus will shift beyond basic documentation to comprehensive ambient monitoring systems that passively collect clinical data, predict outcomes, and optimize workflows without requiring manual input. These intelligent environments will combine voice-activated assistants, automated resource management, and gesture-based controls to create responsive care spaces, enhancing both provider efficiency and patient experience. Organizations will prioritize ROI measurement and specialty care access while implementing robust governance frameworks to standardize deployment of these transformative technologies.”
—Sonia Singh, chief insights officer, AVIA
“Off-label prescribing has become part of the public consciousness due to the explosion in popularity of various medications for weight loss. As off-label treatments become more common, physicians face knowledge gaps and will seek more real-world data as they are currently forced to rely primarily on pharmaceutical studies and prevailing guidelines from medical associations.
These shifts in prescribing practices highlight the need for safe spaces where physicians can openly exchange insights and collaborate on patient care strategies. As we head into 2025, the need for real-time virtual consults among physicians will become even more prevalent, and secure online physician communities will be vital platforms for fostering collaboration on prescribing and treatment practices. These virtual spaces will benefit not only practicing physicians but also the entire medical community and the patients they serve.”
—John Theobald, founder & CEO, Healthcasts
“Enrollment in commercial ACA Marketplace coverage soared in 2024, increasing by 31% to over 21.4 million enrollees driven by several factors including enhanced subsidies. This influx of new members, coupled with increasing regulatory scrutiny around health plan risk adjustment programs, underscores the need for health plans to accurately capture member population risk to ensure appropriate reimbursement.
In 2025, it will be vital for both Medicare Advantage and Marketplace plans to focus on strengthening their risk adjustment programs, including improving medical record retrieval methods, coding accuracy, and strategically integrating technology with human expertise. In each of these areas, plans will need to determine how to best combine external support with their in-house capabilities to reduce internal burdens and improve efficiency. By taking advantage of resources such as the Offices of Inspectors General (OIG) toolkit and leveraging analytics to educate providers on correct coding practices, health plans can capture their population risk more accurately to secure compliant reimbursement.”
—Katie Sender, MSN, RN, PHN, CRC, vice president, Clinical Coding Solutions, Cotiviti
“Reflecting on 2024, it’s clear we’ve shifted from discussing artificial intelligence (AI) broadly to focusing on the transformative potential of generative AI, particularly in the health care revenue cycle. This technology is revolutionizing the way we approach longstanding challenges such as reducing cost-to-collect and addressing staffing shortages. Generative AI unlocks clinical data for use cases like authorizations and coding. For example, in authorizations, generative AI functions as a ‘clinical assistant,’ guiding teams through complex decisions without requiring specialized expertise. In coding, it ensures accurate documentation, enabling health systems to maximize revenue and improve quality metrics. Generative AI is helping teams handle complex cases without requiring extensive clinical expertise.
In 2024, the focus was on building trust and early adoption. As we look ahead to 2025, I predict an acceleration of these efforts. Organizations will prioritize finding the right vendor partnerships to create unified tools capable of leveraging clinical records across multiple use cases. In 2025, I foresee generative AI becoming a cornerstone of holistic revenue cycle operations, breaking down silos, providing consistent insights, and enhancing productivity. This is just the beginning of what is possible with this innovative technology.”
—Amy Raymond, SVP of Revenue Cycle Operations and Deployments, AKASA
“In 2025, health care organizations will continue to increase their cybersecurity efforts, recognizing that cyber risks are among the biggest challenges they face. The surge in cyberattacks we saw in 2024, especially the devasting impacts of the Change Healthcare attack, has made it clear that action can’t wait. Many organizations are already leading the way by conducting business impact analyses, building stronger defenses, and working with expert partners to stay ahead.
Next year, we’ll see more organizations following suit as leaders realize that managing cyber risk is not optional—it’s essential. Investments will focus on smarter, long-term strategies to protect both the technology they’ve had for years and the tools they are adopting now. But not everyone will keep up. To address these gaps, we can expect new rules, stricter oversight, and possibly more funding for smaller hospitals that need help. The stakes are high, and organizations that delay are gambling with patient safety and their own futures.”
—Steve Cagle, CEO, Clearwater
“As predicted, the health care industry saw many advancements in precision oncology in 2024, driven by consumer demand for genetic testing to assess cancer risk. Looking ahead to 2025, opportunities will increase with new developments in liquid biopsy tests that detect circulating cancer DNA cells and monitor cancer progression, treatment efficacy, and recurrence. Simple blood tests conducted over time will allow noninvasive, more precise insights for detecting multiple cancers at early stages and help inform treatment decisions. These tests may complement or even begin to replace current procedures, such as colonoscopies, while expanding screening to other cancers in a single test. We will see direct-to-consumer offerings take off while awaiting payor approval.”
—Dr Joel Diamond, MD, chief medical officer, Aranscia
"The middleman crisis in health care is undeniable, but achieving the right balance of regulation is a daunting challenge. The new administration is correct in identifying the swamp in Washington and the inefficiencies within our bureaucracy. There is a pressing need to streamline and reduce unnecessary bloat; however, indiscriminate gutting of agencies could prove counterproductive.
My concern is that the administration may tackle these priorities in the wrong sequence. If they begin by dismantling the Department of Health and Human Services (HHS) as promised, it could make the health care sector even more complex and costly. Worse, if their efforts to restructure fail, the market could remain stuck in a confused, expensive status quo. A better approach would be to streamline and reform the health care sector first to ensure smoother operations before addressing bureaucratic inefficiencies within HHS. Unfortunately, that doesn’t appear to be the trajectory they are pursuing."
—Navin Nagiah, CEO and co-founder, Daffodil Health
“Medicare Advantage plans will continue to struggle with decreased margins due to risk adjustment policy updates and Stars performance, requiring ongoing innovation to remain competitive. The ‘Silver Tsunami’ and favorable policies from the incoming administration will likely continue to drive growth; however, beneficiaries should prepare for reductions in supplemental benefits.
Ongoing discussions between CMS, provider advocates, and Congress regarding the Medicare Physician Fee Schedule (PFS) reveal significant challenges today. With tensions rising among influential advocacy groups, immediate fixes will likely involve stopgap measures, such as temporary funding increases, to mitigate severe provider impacts in 2025.
The growth of Special Needs Plans (SNPs), particularly Chronic Condition SNPs (C-SNPs), will accelerate in 2025, driven by the increasing prevalence of chronic diseases, slight relief in Stars composite scores, and CMS's emphasis on tailored, high-quality care for complex beneficiaries. Plans will prioritize C-SNP expansions to address these needs while leveraging opportunities for enhanced care coordination and improved outcomes.”
—Cindy Henry, director of Population Health Informatics, ZeOmega
"Throughout the past year, many health care organizations experimented with AI for clinical and operations functions, such as using AI to augment coding. Simultaneously, major IT vendors—including Adobe, Google, Microsoft and Salesforce—have built generative AI features into their ubiquitous business platforms. Routine use of these tools will enhance understanding of how AI capabilities can improve processes, ranging from preregistration to claims adjudication to care management.
Recognition of AI’s power will drive wider adoption of AI-based solutions throughout the health care value chain. Data analysis and predictions will improve with the growth of machine learning applications. Operations will be streamlined through agentic workflows, with autonomous AI agents working together across business functions. Members and patients will enjoy improved care and intelligent experiences as AI copilots assist care managers and service representatives. AI tools will increasingly collaborate within and across organizational boundaries, making organizations with comprehensive AI roadmaps best positioned to achieve meaningful improvements in care and cost efficiency."
—Venkatgiri (Giri) Vandali, president of Healthcare and Life Sciences, Firstsource
© 2024 HMP Global. All Rights Reserved. Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of First Report Managed Care or HMP Global, their employees, and affiliates.
