Payers and providers increasingly agree that operational friction is accelerating healthcare's affordability problem

NEWS SUMMARY

• Payer concern over administrative complexity more than doubled between 2025 and 2026, from 30% to 69%, and both payers and providers now rank it among the top three challenges facing U.S. healthcare, alongside rising costs and workforce shortages.
• Payers and providers show a high degree of alignment on what is wrong with the system, with each side agreeing that reducing friction between them is a shared responsibility, even as they experience the underlying cost drivers differently.
• Fewer than half of payers and providers say they collaborate with one another on cost and quality data. That's true even though both sides are analyzing the very same claims. Closing this gap represents one of the clearest opportunities to reduce friction.

BOSTON: Zelis®, a leading provider of healthcare technology solutions, today announced the release of the 2026 State of the Healthcare Financial Experience, an annual research report in collaboration with Datos Insights.

Based on a survey of health plan and provider organization leaders, the report examines what is driving cost pressure across the healthcare system, where payer and provider views align, and where friction persists. Between 2025 and 2026, the share of payers citing administrative complexity as a top challenge more than doubled, while the share citing rising healthcare costs climbed from 33% to 85%.

"The research tells a different story than the industry narrative suggests. Payers and providers aren't describing two separate problems," said Amanda Eisel, Chief Executive Officer, Zelis. "They're describing the same one, from two sides of the same transaction. That's a unique opportunity for the industry to move from parallel problem-solving to connected action with shared responsibility - and it's the ground Zelis was built to operate on."

The Shared Diagnosis

The alignment of payers and providers shows up across several measures:

• Payers and providers rank healthcare's top three challenges in nearly the same order: rising healthcare costs (payers 85%, providers 74%), workforce shortages (payers 66%, providers 70%), and administrative complexity (payers 69%, providers 66%).
• An overwhelming 95% of payers and 94% of providers agree there is more friction between them than there should be, and 96% of payers and 94% of providers agree most of it could be avoided.
• Similarly, 98% of payers and 95% of providers describe friction reduction as a shared responsibility, while fewer than 2% on either side assign primary ownership to the other party.

Different Root Causes, One Shared Touchpoint

Even as payers and providers agree on the system's top challenges, they point to different root causes. Providers most often cite claims, billing, and reimbursement processes (95%) as their biggest source of cost and operating pressure. Payers most often cite rising treatment costs - specialty drugs (83%), chronic condition management (77%), and utilization (47%). These are genuinely different problems. But both live inside the same claim: the point where a provider's billing meets a payer's cost and utilization review. That shared touchpoint is why neither side can fix friction alone.

The Collaboration Opportunity

That structural divide shows most in how the two sides use claims data. Payers and providers report broad use of advanced analytics, including fraud, waste, and abuse detection (payers 86%, providers 81%), claims trend analysis (payers 80%, providers 92%), and utilization review (payers 77%, providers 83%). Yet only 44% of payers and 45% of providers report collaborating with the other party on cost and quality data.

It is the lowest-ranked analytical activity for both groups, pointing to an operational opening where both sides are analyzing the same transactions with disparate tools and siloed data and reaching different outcomes. With closer collaboration, and more integrated workflows and insights, payers and providers can work on connected paths to solve the same problem.

Why It Matters

Operational friction is not abstract. It carries a material impact that directly influences how patients experience care. The largest performance gap in the study is a 67-point spread between the 96% of providers who say helping patients understand their coverage is critical, and the 29% who say they are effective at it. Every payer surveyed rates clear explanations of benefits as important. Among the 72% who call clarity 'extremely important,' only 21% rate themselves very effective, a 51-point spread. Every bill or benefits statement generates downstream cost, from member service calls to billing disputes and delayed payments. Those costs feed back into the administrative burden both sides are already managing.

This data is the latest evidence that affordability is no longer only a cost problem. It is also an operational one. When asked what will most improve the payer-provider relationship, both groups pointed to the same set of solutions: automation, transparency, real-time data sharing, and artificial intelligence.

"Administrative complexity is the one challenge in this data that both sides agree is fixable through better collaboration, not just through cost controls," Eisel added. "That is exactly where Zelis operates, and it is why we see this alignment as an opening rather than just another data point."

To access the full report and future releases in the series, visit www.zelis.com/healthcare-financial-experience.

Survey Methodology

Analysis is based on proprietary research conducted by Datos Insights between March and May 2026, surveying over 500 leaders across two key stakeholder groups in the U.S. healthcare market: payers and providers. By surveying both sides of the healthcare financial relationship simultaneously, the research captures where perspectives align, where they diverge, and what that means for affordability, transparency, and operational efficiency in healthcare.

About Zelis

Zelis is modernizing the healthcare financial experience across payers, providers, and healthcare consumers. We serve more than 725 payers, including the top 5 national health plans, regional health plans, TPAs and millions of healthcare providers and consumers across our platform of solutions. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts – driving real, measurable results for clients. Learn more at Zelis.com and follow us on LinkedIn to get the latest news.

Fonte: Business Wire