Change is the only certainty for 2025, and we shared several high-impact perspectives in Part I. Now, here’s Part II with more of what you need to know this year. As always, Lightbeam is here you illuminate the most powerful solutions along the way.
Continuing Expansion of Value-Based Care Models
With value-based care (VBC) models rapidly becoming the industry standard, payers will continue rewarding healthcare providers based on patient outcomes rather than services performed. As the landscape matures, the global VBC market is on track to grow from approximately $1.64 trillion this year to reach a projected $3.77 trillion in 2029. The future success of VBC hinges on collaboration among health plans, providers, and community resources to reduce costs while improving health outcomes.
To that end, the Center for Medicare and Medicaid Innovation (CMMI) is focusing on longitudinal accountable care that underscores specialty access. This vision for 2025 and the years ahead looks beyond traditional medical care to improve whole-person health and total wellbeing, which includes social determinants of health (SDOH), such as food security, housing, and lifestyle challenges. The goal is to engage patients more effectively and build healthier communities while reducing healthcare costs. A purpose-built, AI-powered population health management platform like Lightbeam Health can help you make the best choices from a quality and cost perspective to improve clinical outcomes at all levels of care.
Behavioral Health: Next Frontier for Value-Based Care
Driven by the urgent need for affordable mental health and addiction services, particularly among Medicare beneficiary populations, the Centers for Medicare and Medicaid Services (CMS) is introducing the Innovation in Behavioral Health (IBH) Model to improve the quality and integration of care. The program will include a new CMS network adequacy evaluation standard that requires networks to offer the correct number of providers that specialize in mental health and addiction issues. As of Jan. 1, 2025, the new regulations require insurers to cover mental healthcare at the same level as other health services—prohibiting health plans from assigning more stringent prior authorization requirements for mental health than for other forms of care. CMS projects a 2.8 percent increase inpatient rates in 2025.
Other regulatory measures that support the increasing focus on mental health and addiction in 2025 include reimbursement for FDA-approved digital therapies and regulation changes that introduce separate coding and payment for patient safety planning interventions. In addition, the Drug Enforcement Administration is extending telemedicine policies that allow for virtual prescription of controlled substances to enable wider access to digital mental health treatments and more flexible medication management.
These significant changes will require payers and providers to make fiscal management adjustments to absorb increased systemwide costs. Therefore, we advise careful planning and preparation for 2025.
Increasing Emphasis on Health Equity
CMS’s announced focus on health equity signals a shift in how healthcare systems will address disparities. The CMS Health Equity Index is designed to ensure all beneficiaries, especially those from underserved communities, receive equitable access to care at all levels.
As CMS expands health equity to Medicare Advantage, the winners will focus on operationalizing tangible, incremental improvements. In 2025, every health plan, including Medicare Advantage plans, will be required to have a physician with health equity expertise on staff to evaluate its utilization management policies and procedures, which could include strategies to improve star ratings, as well as health outcomes in underserved populations.
Further, CMS has confirmed that redefining utilization management policies through a health equity lens will continue to be a priority, including the integration of SDOH data. These new measures will launch in 2027, but the capture years are 2025 or 2024/2025, meaning that some of the health equity changes adopted in 2024 are still in the initial data-collection phase. More to come.
Erin Page, President and Chief Operating Officer, Lightbeam Health Solutions
Significant Growth of AI Vendors and Applications
Artificial intelligence (AI): It’s where we begin and end as we prepare for 2025. This year, demystifying AI will be the priority. That requires we move from talk to action and from handwringing to implementation. It’s time to jump in. The best way to start is small—with a discrete task or function, focused on automation in a targeted operational workflow. This avoids the concerns about hallucination and error generation associated with some large language models like ChatGPT and helps guide your purchase decisions.
Teaming with a trusted, proven partner like Lightbeam AI, healthcare payers and providers will benefit from a customized taxonomy and purpose-built platform. Using data-driven and generative non-patient-facing solutions, you can significantly improve administrative efficiencies and enhance quality measures to satisfy increasingly stringent payer requirements.
As part of our government shift, we are likely to see expansion of Medicare Advantage and relief around reimbursement. In keeping with the continued emphasis on VBC and specialty integrations, there will be growth in dual-eligible and special-needs plans. We also can expect increasing investment in primary care—adjusting fee schedules to balance revenue opportunities for primary care providers (PCPs).
The year will bring transition, change—and a surprise or two. So, now is the time to prepare. The opportunities to improve patient outcomes and lives are unlimited. Whether payer or provider, the right tools can position you for success today—and tomorrow.
Matt Kamen, Chief Product Officer, Lightbeam Health Solutions
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