Navigating the Turns: Steering Health Benefits Through Economic and Clinical Transitions

J Clin Pathways. 2026;12(2):e004.

This year’s Milano Cortina 2026 Olympic winter games included the sport of bobsledding, which requires multiple skills for success measured to a hundredth of a second. The sport consists of a team of 2 or 4 persons and an ice track with more than 15 turns. In order to achieve the fastest time, bobsled athletes must focus and use their expert skills to navigate a narrow inclined and twisting ice track.

Much like bobsledding, the health care industry is having to face multiple issues simultaneously while change occurs in certain areas. For instance, there has been a rapid acceleration of technologies while economic pressures are driving up costs along with supply chain disruptions and political uncertainty. Economic pressure demands skillful budgeting and health plan design with realistic expectations for funding it. Analytics can assist but it requires disciplined execution.

This column will explore how the current business landscape is affecting health benefits as initial thoughts for 2027 plans are underway, and how clinical pathways continue to evolve from clinical only to integrated health care business tools.

Up to this point in 2026, CEOs have been maintaining optimism for company growth while managing economic uncertainty, geopolitical volatility, and prohibitive costs.¹ The focus on profitable growth and cost discipline has caused organizations to re-evaluate expenses as opposed to adjusting along with zero-based accounting practices.

At the same time, affordability and accessibility are now defining the US health benefit plan landscape. In 2025, the total health benefit cost per employee was projected to rise by 6.5% in 2026. ² Since the beginning of 2026, the cost has risen to over 10%, another double-digit increase post-pandemic.³ Specialty drugs, chronic disease management, and use of GLP-1 drugs for weight loss are among the top drivers for the year-over-year growth in plan cost.⁴ 

According to WorldatWork, “[A]lmost three-quarters of American workers say benefits matter as much as—or more than—their pay."⁵ This puts pressure on employee benefits as it plays an outsized role in retention and productivity while aiding in recruitment.^6,7  Workforce interest in a broader well-being experience and personalized benefits reinforces the theme of whole person health strategies. For example, just as there has been a major shift in emphasizing skills— both upskilling and reskilling—as a benefit for employee retention and hiring, employers have begun offering more preventative care and enhanced whole person care options.¹ Such back-to-the-basics strategies from past decades could assist in mitigating higher health services utilization and subsequent cost, rapid adoption of advanced medical technologies, and the growing impact of high-cost medication therapies like GLP-1 therapies.⁴ 

A common question employer plan sponsors ask is whether they are getting everything as promised by analytics. Also, as health care costs continue to rise, what is the best way to invest in value-based care and targeted programs addressing chronic conditions? And what are the best funding strategies that work best for the company and its employees, while having benefits strategies that are attractive to all concerned? Much of these concerns can be tied to a clinically effective solution for managing all of the plan’s dynamics.

There have been a few key governmental and commercial insurance efforts to address clinical and business issues within health care. Starting in hospital inpatient medical and surgical care delivery, the idea of clinical pathways for care management emerged during the late 1960s-1970s. Ultimately, an effective and efficient clinical pathway was implemented as Diagnosis Related Groupings (DRGs) under the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 as a prospective payment system to stop price inflation. Hospitals also established quality initiatives to address structure, process, and outcome measures to standardize care within their medical staff. In addition, the Centers for Medicare & Medicaid Services’ (CMS) established peer review organizations focused on Medicare payment overview. These efforts led to program cost reductions but opened the door to more vigorous business applications that continue to evolve through technological innovations.⁸

In the 1990s, forcing hospitals to manage costs by a flat fee regardless of actual costs led to the development of clinical pathways (CP) from the original critical pathways’ language. CP evolved from quality initiatives to reduce variability in clinical practice toward business focused tools to manage the economic risks represented by DRGs. By 2008, insurance companies and managed care increasingly used their own clinical pathway program—especially with oncology care—to enforce medical care patterns for multiple settings of care. As a result, lengths of hospital stays dropped, workflows reduced waste, and adherence to evidence-based guidelines could be more easily monitored and achieved by care entities and payers.⁹

As care transitioned away from inpatient care, CPs began to follow the increasing variety of care settings delivering medical and surgical care services or therapy. As with hospitals earlier, the shift toward business tools reduced unwarranted variations in care and led to standardization and cost efficiency. Starting in January 2016, a new initiative under CMS titled Comprehensive Care for Joint Replacement Model (CJR) allowed electronic clinical pathways to ensure patient success and positive financial return for hospitals and stand-alone surgical centers later on. The CJR focused on quality and efficiency improvement from the entire pre-operative through post 90-day discharge period for hip or knee replacement paid by Medicare. All these efforts reflected a desire to manage the total cost of care with the same or enhanced outcomes from care or therapy delivered.¹⁰

The global pandemic in 2019-2022 further transformed where and how care was delivered.  In collaboration with distant care organizations, patients (consumers) could use technology outside of a local hospital for their care. This need for flexibility forced another transition in the application of CP applications as an integrated clinical and business process for care optimization along with payment or plan coverage.

Current 2026 development of CPs foretells a role in alternative plan design, payment, and cost management strategies that are likely to grow faster by 2030 due to the use of artificial intelligence. It seems certain that the CPs in the next decade will look and operate little like the CPs from the last century.

For business CEOs, today’s market challenges are seen as structural and not temporary, which has led them to prioritize optimizing operations and improving worker productivity. There are and will be many calculated risks taken along the winding 2026 health insurance journey. Employers will likely have a more proactive mindset that will lead to modeling scenarios, accountability, and a focus on outcomes to successfully support their workforce while controlling costs.

Empowering patients has become more common given the current comparative state and business importance of US health care for other industries. As such, health insurance trends for both medical and pharmacy coverage may see movement from traditional one-size-fits-all coverage toward less restrictive, more tailored, and higher shared cost (eg, deductibles, copayment, or coinsurance) in 2027. It is likely that employers will seek more uses for CPs including real-time applications incorporating CPs into plan coverage options at the point of service.

The interconnected yet competing priorities of economics, access, and outcomes of care remain important intersections of the “Iron Triangle of Healthcare” since its 1994 release.¹¹ The intersections of the Triangle will continue to constantly change and feel disruptions requiring innovation and time to solve. Maintaining focus, skills, and a sense of speed—just as in bobsledding—is more important than ever as we begin thinking of health coverage for next year. This is true for care delivery entities or providers, employer plans, and patients as consumers of care.

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2. Umland B, Patel S. Employers prepare for the highest health benefit cost increase in 15 years. Mercer. September 3, 2025. Accessed February 23, 2026. https://www.mercer.com/en-us/insights/us-health-news/employers-prepare-for-the-highest-health-benefit-cost-increase-in-15-years/
3. Bannow T. GLP-1s, cancer care are driving higher employer health care costs in 2026. STAT+. August 20, 2025. Accessed February 23, 2026.https://www.statnews.com/2025/08/20/health-costs-going-up-heres-why/
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8. Centers for Medicare & Medicaid Services. Design and development of the diagnosis related group (DRG). CMS.gov. October 1, 2019. Accessed February 23, 2026. https://www.cms.gov/icd10m/FY2026-fr-v43.1-fullcode-cms/fullcode_cms/Design_and_Development_of_the_Diagnosis_Related_Group_(DRGs).pdf
9. Hipp R, Abel E, Weber RJ. A primer on clinical pathways. Hosp Pharm. 2016;51(5):416-21. doi: 10.1310/hpj5105-416 https://journals.sagepub.com/doi/10.1310/hpj5105-416#tab-contributors
10. Centers for Medicare & Medicaid Services. Comprehensive care for joint replacement (CJR) model: performance year 6 evaluation report—executive summary. CMS.gov. 2024. Accessed April 16, 2026. https://www.cms.gov/priorities/innovation/data-and-reports/2024/cjr-py6-ar-exec-sum https://www.cms.gov/priorities/innovation/data-and-reports/2024/cjr-py6-ar-exec-sum
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