Business Trends Shaping the Future of Clinical Pathways

J Clin Pathways. 2025;11(1):62-64.

Welcome to the new Transformative Business Trends column, de­signed to complement our recurring Transformative Employer Trends column, which focuses on how employers are weaving clinical pathways into their coverage plans. This column will dive into business trends that are or will transform clinical care along­side pathways. Year after year, we deal with these same issues, and year after year, surveys show mostly the same things. Yet, we continue in our dreamy state, dreaming of a health care journey as it could or should be instead of actively making it more valu­able and quality-focused to achieve optimal patient outcomes.

For businesses, 2025 brings another year of significant health care cost increases. Along with it come contemplations around moving from a fully insured plan to a self-insured one. Moreover, if you are already self-insured, you may want to contemplate “level funding.”

What hasn’t changed is the number of third-party fingers in the overall health care pie, and yet we don’t seem to have reached a real tipping point even though it is clearly coming. As advances continue, manufacturers continue to stoically point fingers or throw their hands up in the air and wonder what to do with slow market uptake, etc.

Role of Insurance

Self-funding has grown substantially from its humble begin­nings. Since 1986, it has been a real force in the national sys­tem.¹ It continues to grow within commercial insurance plans and is an important economic risk sector among the varied payer mix in US health care.^2,3 It also has a vital role to play in both access and quality as we try to address a broken system. Solutions have varied from point-specific to systemic, but what is well-known is that today’s options are not working well and often create “no coverage” or inadequate/inappropriate cover­age situations. Additionally, the asynchronous timing of vari­ous actions by the different stakeholders can result in chaos, escalating costs (as we have repeatedly observed), or worse.

There are several challenges to addressing a systemic prob­lem with a systemic solution, including:

• Existing coverage options not working well, creating growth in the number of plans using “no coverage” provisions.
• Patient-centric paths for potential future insurance risk financing strategies.⁴

Asynchronous timing of stakeholder actions creates conse­quences, adding to chaos and escalating costs as each stake­holder in the current system operates in a silo vs an integrated system. Even manufacturers operate two different business timelines: one for research and development (R&D) and one for therapeutic product marketing. The lack of internal inte­gration of business timelines and a growing gap in knowing the other business stakeholders’ timelines has fueled a complex patchwork of band-aid solutions. Such financial and clinical so­lutions generally have adversely impacted patients or providers. Key opportunities to simplify and work toward solving access or costs include the following:

• Forecasts more realistically utilizing patient-oriented pathways during clinical development in collaboration with commercially-insured plans and their advisors. This will improve predictability and future risk exposure, which is beneficial for all involved in the business of health care.
• Solve supply and demand in the marketplace through transparency in all aspects of money flows for products or therapies. Clarity in utilization can better inform prescriber or user demand and supply needed to meet such demand more accurately. Doing so improves the balance required to effectively finance care innovation when approved for marketing.

Role of Employers

Since much of US health care is employer-funded or employer-driven through commercially-insured offerings, they must play a vital role in moving us forward.

Here are some actions employers can take to help improve their reality, including but not limited to:

• Review strategies for better health access/equity that include direct input from employee members to get a better/deeper understanding of their health status to tailor the insurance structure better;
• Take a closer look at plan designs and make changes as needed;
• Question brokers, advisors, and others more deeply about your particular scenario and how problems were solved;
• Put programs in place that address the site of care, high-quality providers, etc;
• Take a closer look at pharmacy benefit managers (PBMs), drug channels, and pricing;
• Consider the appropriate use of technologies like digital health and wearable technologies to help employees and their families on their clinical journeys; and
• Gain a better understanding of what is out there in terms of solutions.

Centered and evidence-based care around a member (and not the PBM or anyone else) can also improve clinical pathways and outcomes that will positively impact health care risks and costs. Critical thinking is required in order to experiment with differ­ent things to see what works best. Continually deploying cost-shifting strategies, such as raising premiums and/or deductibles, will not address the underlying problems facing US health care.

Role of Manufacturers

Manufacturers also have a vital role to play in this future state. Some of what they can do is relatively easy, while others are more complex. Ultimately, both the employers and manufacturers want the same thing. For example, they need transparency in data so they can both make more informed decisions regarding con­sumer access and care. The reason why they want it may not be the same. Employers care about cost and competitive advantage, while manufacturers care about R&D, therapy access through efficient coverage plans, and appropriate product utilization.

R&D timelines need to typically fit much better to solve commercial marketplace issues and buying patterns vs manu­facturer marketing divisions. Clinical pathways, especially with real-world evidence, are essential for all parties if data access issues are solved.

Developing solution collaborations between employers and manufacturers, in particular, could be crucial. This is due to their importance in driving change and establishing a differ­ent engagement model, which has not been seriously done in decades. The late 1990s through 2000s saw more innovative, collaborative benefit models with Pitney Bowes^5,6 in Connecti­cut and The Asheville Project in North Carolina⁷ that worked.

Those multistakeholder efforts demonstrated a better and more innovative path forward through the system in selecting care access differently through a patient-centered lens.

Manufacturers play a significant role in the future of health care. Their ownership in stakeholder market share is becoming more and more obvious (alarming) to consumers with new trending discussions on big pharma, antivaccination movements, and viral misinformation.

Manufacturers could benefit from positioning themselves as a strategic collaborator of employers to help better educate and empower consumers on cost-of-care interruptions and pock­eted rebates that deter consumers from accessing their drugs and treatments.

Another collaboration effort includes R&D-backed edu­cational campaigns that align with employer benefits devel­opment through implementation timelines better fit to solve commercial marketplace issues and consumer buying patterns.

Clinical pathways, especially with real-world evidence, are an important tool for all parties if data access issues are solved. Whole person care and patient-centered care for each member can also improve clinical pathways development, adoption, and performance outcomes to impact health care risks and costs.

Doing so requires a committed, ongoing collaboration among employers and manufacturers, not just the traditional annually-based direct contracting approach.

Business trends and financial considerations inevitably im­pact clinical care or patient journeys through a medical condi­tion. This initial column explores a few different stakeholder roles that have a more prominent impact on health care business trends. Future columns will expand or delve deeper into other business aspects related to or influenced by clinical pathways.

Commercial health insurance, employers, and manufactur­ers play interrelated and critical roles in allowing for an overall change in the business of health care. The harsh reality is that we do a lot of talking about our challenges in health care, but we don’t bring parties together to efficiently solve actual prob­lems. With the increased speed of new treatment options and therapies, the speed of collaboration must also match it if we are to make a meaningful impact in US health care cost trends.

Now is the ideal time to actively address the solutions need­ed for the near future. By collaborating with industry partners, we can more effectively resolve challenges such as improving data flows, streamlining patient journeys, and designing cost-effective benefit plans that benefit all stakeholders.

Reader questions, feedback, and suggestions are always wel­come and can be directed to JCPEditors@hmpglobal.com.