Managed Care Reflections: A Q&A With Melinda B. Buntin, PhD

Am J Manag Care. 2025;31(6):In Press

AJMC: How have the concept of managed care and the conversations around it changed over the past 30 years?

BUNTIN: It’s really fun to think about this and realize how far we’ve come. I think back to the original versions of managed care, where many plans were either staff models or were homegrown based on local provider networks, and now those are a distinct minority, and what we have are very large national plans and sometimes consolidated versions of plans. The industry has changed tremendously, and with it the conversation, so you’re no longer talking about a Kaiser or a local plan built around a large group practice. We’re now talking about the Uniteds and Humanas and others of the world, and they operate very differently. They have strengths in terms of scale and scope, but they are not as customized to their local markets and/or they’re not an employer of medical professionals. Although I do understand that United is now one of the largest employers of medical professionals, that still doesn’t constitute a large percentage of the people delivering care to their members. It’s really changed so much. Now, of course, MA [Medicare Advantage] is over 50% of the Medicare population. That’s an astounding change over the past 30 to 40 years.

AJMC: What changes do you see taking place in managed care over the coming years?

BUNTIN: I think changes to managed care will be similar to the changes for the health care industry as a whole. And the first one that pops into mind, of course, is AI [artificial intelligence]. We know that health plans are already trying to figure out how to use AI for prior authorizations and certain types of patient interactions. I think we, as a society, are developing a level of comfort with some of these types of interactions, but not with others. For example, the idea that you want a medical professional to be the final word on a prior authorization—that I suspect will stick around for a while, even if initial prior authorizations are done through AI algorithms. But this is a new world for us in so many parts of our lives, and I think the medical industry is particularly ripe for these types of interventions because there is so much variation in practice, and because it’s so human labor–intensive at this moment.

AJMC: In 2011, you authored a study in AJMC that found enrollment in a higher-deductible health plan (HDHP) was associated with lower health care spending but also lower preventive care use.¹ How has our knowledge about HDHPs and consumer-directed health plans evolved since then? Enrollment rates in HDHPs have dipped in recent years; could this be because enrollees are prioritizing other factors when choosing plans?

BUNTIN: Let me take a step back and say that this is an interesting topic. When I started a project looking at high-deductible and consumer-directed health plans, it was during a period when they were very popular among Republicans who were then in power here in [Washington,] DC. By the time the article came out, it was after the Affordable Care Act, which really hadn’t emphasized consumer orientation in combating issues related to cost, access, and quality. I just want to say to everyone publishing in the world of health policy: Sometimes you’ll start a project, and where the world is when you finish it may have changed. But in this case, I think the article has had fairly long legs and continues to be cited. And I’m really grateful to AJMC for seeing the value in the work, which we sought to be the most rigorous study published at that point. Our model at the time—I was at RAND—was to be the new version of the RAND Health Insurance Experiment by using modern observational study methods as opposed to a true experimental design, and that is what we did to the best of our ability.

I think that article has really held up. Most of the literature since then has seemed to confirm these general findings, and I am also happy to see that the people I worked with at RAND, like Neeraj Sood, Amelia Haviland, and Peter Huckfeldt, have continued to publish in this area, in some cases using that very same database that my grant was the first to fund the compilation of and, in some cases, on updated sets of data. They are really the experts in this field. They’ve published many more articles since then, and they’ve been doing things like looking at longer-term effects of consumer-directed health plans, effects on low-value care, cancer screenings, and the like, really adding to our understanding of the effects of these types of plans.

Of course, at the same time, I look back at what we defined as a high-deductible health plan at the time, and it almost seems quaint, because deductibles have gone up so fast—most people now are in what we would have back then called a high-deductible plan. So, the world has changed, and I think that makes the results even more interesting and important, because so many people are faced with high deductibles; we know that that affects their care-seeking behavior.

AJMC: Other articles of yours published in AJMC in the 2010s^2-4 explored hospital adoption of electronic health records. Now that this adoption in hospitals is nearly universal, what do you think is the next frontier of technology or innovation that will be important to monitor for equitable uptake?

BUNTIN: I don’t want to sound like a broken record by going on about AI again, but, of course, AI-assisted decision-making is something we need to monitor. There’s been lots of excellent work done on potential for bias, for example, in AI models that are trained on patterns that are themselves inequitable, so that’s something to watch. But in the area of electronic health records in particular, a challenge that we had back then, when I was working on the implementation of the HITECH [Health Information Technology for Economic and Clinical Health] Act, which was promoting the adoption of electronic health records by doctors, hospitals, and other health care organizations and providers, was the issue of interoperability. It was a challenge then; it’s still a challenge now. And since you asked about equitable uptake, I will say that one of the patterns that we’ve seen is that the very large players in the electronic records space, players like Epic, are able to offer their clients a degree of interoperability. If I’m seen by a hospital that has Epic, there’s a good part of my record that can be seen by a provider in another organization or another geographic area that’s also using it. But Epic is the very high-end model, and not everyone can afford it, especially smaller providers, so we now have interoperability for a segment of the market, but not the whole market. We think it’s something that’s good to keep pressing on, and even though there’s been a lot of reorganization in HHS, I hope this stays high on the agenda.

AJMC: Recently in the New England Journal of Medicine, you and coauthors published a perspective piece on the recent slowdown in health care spending growth.⁵ How could value-based care have contributed to this slowdown, and do you think we will see these value-based efforts sustained in the years to come?

BUNTIN: I think that that is the question. When I was looking at health reforms a decade and a half ago, I used to call them trillion-dollar questions. This might be the $10 trillion question. The argument that my coauthors and I made in that piece in the New England Journal of Medicine was that value-based care did contribute to this slowdown. It was not the only thing; there were other trends—demographic trends, trends in prices and payment rates, especially in federal programs—but there’s a large part of this spending slowdown that is not attributable directly to these types of measurable factors. And we termed the fact that this residual is associated with lower spending growth the value zeitgeist.

The idea is that the emphasis on value caused decision makers throughout the health care system—doctors, hospitals, other health care organizations—to make different types of investments, to alter their care processes, to engage in contracting that may be value-based or at least quality- or price-targeted, and to train their workforce to think about value. All of this contributed to a slowdown in the rate of growth of health care spending compared with prior decades.

I think we’re at a very critical inflection point right now because a lot of the formal evaluations of value-based health care demonstrations, like those done by the Center for Medicare and Medicaid Innovation, have come to the conclusion that those demonstrations saved a few percent on health care spend. But I would argue that they were comparing them [with] a control group, if you will, that wasn’t a true control group, because this value zeitgeist has really permeated the whole health care system, the whole health care industry, for arguably about 20 years now. And so the question is whether we’ll draw what I would argue is the wrong conclusion from these evaluations and think that value-based care wasn’t and isn’t important. If we do that and we pull back, then I think we will start to see health care spending growth increase. We know there are going to be price pressures because of all the forces going on in the world, which I don’t need to list, but whether we’ll be able to keep that focus on value and keep the innovation in the value-based care sector, that is, I think, what’s on the line. That is what maybe I should be calling, going forward, the $10 trillion question.

REFERENCES

1. Buntin MB, Haviland AM, McDevitt R, Sood N. Healthcare spending and preventive care in high-deductible and consumer-directed health plans. Am J Manag Care. 2011;17(3):222-230.

2. Maxson ER, Buntin MJ, Mostashari F. Using electronic prescribing transaction data to estimate electronic health record adoption. Am J Manag Care. 2010;16(suppl 12 HIT):e320-e326.

3. Blavin FE, Buntin MJB, Friedman CP. Alternative measures of electronic health record adoption among hospitals. Am J Manag Care. 2010;16(suppl 12 HIT):e293-e301.

4. Jha AK, Burke MF, DesRoches C, et al. Progress toward meaningful use: hospitals’ adoption of electronic health records. Am J Manag Care. 2011;17(spec No.12):SP117-SP124.

5. Buntin MB, Meara E, Colla CH. The value zeitgeist—considering the slowdown in health care spending growth. N Engl J Med. 2025;392(15):1463-1466. doi:10.1056/NEJMp2413472