What comes next: How providers can prepare for the next era of payor economics in 2026

Managed care is at an inflection point.

Across the industry, payors are showing steady revenue growth, but margins are under pressure, cost trends are volatile, and the mechanisms that have long underpinned managed care profitability are strained. What’s emerging isn’t just a tighter year. It’s a more strategic recalibration. Payors are shifting their posture, and providers should be doing the same — but on their own terms.

The economic model is changing. And those who move deliberately, with discipline and clarity, will be positioned to protect their margins, assert their value, and lead patients to better care and outcomes.

What payors are really signaling: return to fundamentals, but with more precision

While recent quarters showed elevated utilization and fluctuating medical loss ratios, the bigger signal is what’s happening inside payor strategy. You can hear it in CEO commentary and see it in 2025 and 2026 guidance:

• Margin recovery in Medicare Advantage depends on benefit design discipline, network optimization, and tighter Stars alignment.
• Network performance is being re-weighted, not just on cost, but on contribution to total cost of care and quality metrics.
• Supplemental benefits and risk adjustment strategies are being reassessed for ROI, not just growth optics.

It’s also worth noting that while margins are down, overall profit remains strong. The story is not about financial strain across the board, but about prioritization. Investors continue to expect earnings performance, which means expense containment will come at the expense of providers, not shareholders.

This shift is more than financial; it's philosophical. We're watching the reassertion of payor dominance over the health care value chain. That may play well for shareholders in the short term, but for providers, it means facing a decision point: adapt your model and messaging to assert relevance or become a margin lever in someone else’s spreadsheet.

Providers: Be the solution, but not the scapegoat

It’s not just about rates. In 2026, every renewal, renegotiation, and new partnership opportunity will reflect this pressure. If providers aren’t prepared to counterbalance that pressure with hard data and performance accountability, they’ll get boxed into roles that protect payor margins at the cost of their own.

The playbook providers need to assert their value includes:

• Addressing cost volatility in high-pressure areas and implementing automations where possible
• Quantifying impact on Stars and HEDIS measures
• Ensuring risk adjustment integrity and clinical documentation accuracy
• Articulating experience and access outcomes with the same rigor as utilization

And let’s be clear: The burden to justify value is being shifted from the insurer to the provider. The new normal isn’t shared accountability; it’s performance-based survival. Providers must build negotiation strategies not only to keep contracts but to prevent commoditization.

Five strategic imperatives to protect your position and power

As 2026 approaches, providers need to anticipate how payors will act and plan accordingly. The goal is to prepare for a tougher environment with a stronger stance, a clearer story, and tighter grip on the numbers. Why? Because they and the third parties they are sponsoring will come from your nonprofit status if you don’t.

1. Know your economics contract by contract.
   Understand margin by product line, geography, and service type. If payors are modeling your data more precisely than you are, that’s a risk.
2. Frame your performance in economic terms.
   Don’t just report on quality. Show the impact of your model on Stars, risk scores, and total cost of care. Tie your story to outcomes that affect payor margin.
3. Plan renewals with offensive strategy.
   Don’t wait for the payor to set the pace. Run benchmarks, assess escalators, model scenarios. If you’re not driving the timeline, you’re reacting to it.
4. Push for shared risk where you can control outcomes.
   Don’t absorb risk for services where you don’t have the ability, the market share, and the clinical expertise supported by technology. But if you can improve cost, coding, or Stars, show the payor the math and claim a share of the upside. You might just have to be willing to terminate over it.
5. Be ready for conflict.
   Some negotiations will require a termination notice and then a public dispute. Have the PR plan, legal strategy, and operational response mapped in advance. Public disputes are now more important than ever to obtain increases above inflation.

The opportunity ahead: Define your value or be devalued and be acquired

Payors are tightening their models, but they’re not closing doors to strategic partnerships. They are, however, being more selective and more skeptical.

That creates opportunity, but only for providers who meet this moment withevidence, capabilities, and a refusal to be passive.

This is not about appeasing payors. It’s about showing up as a performance-driven partner who knows the value they bring and won’t accept being commoditized.

If providers want to lead, they have to claim that ground now.

Kevin Thilborger is Chief Revenue Strategy Officer at Unlock Health.