JULY 2026 | ISSUE 001
The Health Plan Operator’s Brief
What health plan leadership teams should be discussing this month.
WHY THIS MONTH MATTERS
There is a rhythm to every health plan year…
January is execution.
Spring is measurement.
July is reflection.
By the beginning of the third quarter, most organizations know far more about the year than their dashboards suggest. Quality trends are emerging. Risk adjustment programs are revealing operational strengths and weaknesses. Claims experience is becoming clearer. Technology leaders are beginning to gather investment priorities. Business units are quietly asking which initiatives deserve additional funding—and which no longer do.
This is one of the most important leadership transitions of the year. The conversation begins to shift from operational execution to strategic investment. That shift feels different in 2026. Not because of a single regulation or technology. Because multiple forces are converging simultaneously.
Margin pressure.
Coverage uncertainty.
AI.
Interoperability.
Clinical workforce constraints.
Growing expectations from members and providers.
Individually, none of these trends is new. Collectively, they are reshaping how health plans think about operations. Increasingly, the strategic question is no longer:
"How do we add another capability?"
It is:
"How do we build an operating model capable of using the capabilities we already
have?"
That distinction matters.
The organizations that emerge stronger over the next several years may not be those with the largest technology budgets. They will likely be the organizations that can consistently convert
clinical information into better operational decisions.
OPERATOR'S OBSERVATION
Every budget season eventually becomes a conversation about capability.
Projects consume funding.
Capabilities create options.
TEN QUESTIONS LEADERSHIP TEAMS SHOULD BE ASKING RIGHT NOW…
1. Which initiatives have demonstrated enough value to justify additional
investment?
Funding should increasingly follow measurable operational improvement rather than historical ownership.
2. Where are we rebuilding the same clinical evidence multiple times?
If quality, risk adjustment, utilization management, and care management each recreate the same clinical picture independently, the issue is not staffing—it is architecture.
3. Which manual workflows still exist because information arrives too late?
Many manual processes are compensating for delayed or fragmented clinical information rather than solving inherently complex problems.
4. Which AI initiatives are constrained by organizational design rather than
technology?
Most AI pilots do not fail because of algorithms. They struggle because workflows, governance, and decision rights remain unchanged.
5. What enterprise capabilities are we funding repeatedly through different
vendors?
Duplicate capability often hides behind departmental budgets.
6. Which compliance investments could become strategic capabilities?
Regulatory investments should create reusable infrastructure rather than isolated projects.
7. Where do clinical and financial decisions remain disconnected?
Clinical insight increasingly determines financial performance. Organizations should evaluate where those conversations still occur independently.
8. Which KPIs tell us what happened rather than what is happening?
Lagging indicators explain yesterday. Leading indicators improve tomorrow.
9. Which operational decisions lack sufficient clinical context?
The quality of decisions increasingly depends upon the quality and timeliness of clinical information.
10. If we had to remove 10% of administrative cost next year, where would we
begin?
The answer often reveals where operational complexity has quietly accumulated.
KPI WORTH EXECUTIVE ATTENTION THIS MONTH
Rather than reviewing every dashboard equally, leadership teams should pay particular attention to metrics that reveal whether capabilities—not just programs—are improving.
Clinical data reuse: Are multiple departments leveraging the same validated clinical information?
Manual chart retrieval: Is dependence on manual evidence gathering increasing or decreasing?
Workflow cycle time: Where does information wait? Where do people wait? Those are often different questions.
AI adoption within workflows: Not pilots. Not demonstrations. Actual production use that changes daily work.
Cross-functional operational dependencies: How many initiatives require multiple departments to reconstruct the same information?
CAPABILITIES BECOMING STRATEGIC
Organizations increasingly compete on capabilities rather than projects. Watch for growing investment in:
• Enterprise clinical data reuse
• Decision support embedded into workflows
• Workflow orchestration
• Evidence management
• Clinical identity and provenance
• Operational governance
• AI embedded within existing work rather than separate applications
These capabilities rarely belong to one department. Increasingly, they become enterprise assets.
PREDICTION
Over the next 18 months, successful health plans will increasingly evaluate technology
investments based on one question:
Does this create another project...or does it create an enterprise capability?
The organizations that consistently choose capabilities will build operating models that become progressively easier to improve. Those that continue funding isolated projects will find themselves solving the same problems repeatedly.
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About The Health Plan Operator's Brief
A monthly executive briefing offering my personal perspective on the strategic, operational,
and technological forces reshaping health plans. Written to inform discussion—not to promote products or predict the future. The views expressed are my own.
-John G. Murtha