Advis 2025 Healthcare Predictions

As the healthcare landscape continues to evolve, staying ahead of emerging trends is more critical than ever. Advis leaders share their top predictions for 2025, offering insights into the innovations, challenges, and opportunities that will continue to shape the industry. 

Ryan Bailey, J.D.| Vice President 
Potential Legislative Activity and Related Site Neutral Impacts for CY2024
With the likely passage of the healthcare package in the pending Continuing Resolution, Congress appears ready to tackle several of the “hot topics” of recent. On the positive side, these considerations include mitigation of the Medicare payment cut to physicians and again stalling the cuts to Medicaid supplemental funding for safety-net hospitals, while also extending telehealth waivers and the hospital at home program. On the negative side, these considerations seem likely to also include mandatory compliance attestation filings and separate NPIs for each off-campus hospital outpatient department (“HOPD”). If this language indeed passes into law, in CY2025, Advis predicts that numerous health systems across the country will be faced again with the determination of whether to continue to support HOPDs and file the mandatory compliance paperwork, or transition these sites to physician-based clinics. This decision also closely interplays with any 340B strategy, as these HOPDs are often eligible child sites under the program. Any hospitals that chooses to continue to provide off-campus HOPD services will need to thoroughly review compliance, remedy gaps, and get prepared to file the likely extensive attestation documentation for each off-campus HOPD site. For those that choose to transition services to physician-based, a financial impact analysis will be key, as well as strategic discussions to identify options to help mitigate the impact. The CMS rulemaking cycle will also be important to monitor to see how these requirements unfold, with the proposed outpatient rules typically released in July and finalized in November.

Monica Hon, J.D.| Vice President and Director of Client Solutions  
Virtual Reality and the Medicare Managed Care Take Over—Good News or Bad? 

Under the newly elected administration, commercial insurers’ regulatory framework is expected to loosen. This is bad news for healthcare providers and hospitals across the country. As a result, we expect an increase in the number of Medicare Advantage Plans in the market and a continued reduction in standard Medicare utilization. As any hospital operator will confirm, reimbursement delays, denials, and coverage issues are commonly experienced with Medicare managed care claims. With less regulatory oversight, it will be easier for them to deny claims or delay payments.  

Health care finance teams will need to keep a close eye on managed care partners and contract updates. Collaboration, networking and sharing ideas with peers will be necessary for hospital leaders as they keep up with the forthcoming changes. Their ability to navigate this turbulent time will be enhanced as a result. 

Expect some good news in 2025 with continued innovation using AI, specifically an increase in innovative practices in mental health care nationwide. We witnessed VR therapy hit the market nationally with VR therapy utilizing a computer-stimulated world as a treatment tool to practice skills safely or reduce fears. In 2025, we can expect VR to play an increasingly important role as the behavioral health industry strives to meet the demand for expertise for so many people in need of various levels of care. 

Jake Beechy, J.D.| Vice President 
340B Crossroads 
If you are involved in the 340B program, you already know the program is at a crossroads. Last year, we predicted that Congress would have to get involved, and they did. However, in typical fashion, failed to execute. The Congressional stakeholders issued two bills to overhaul the 340B program, requested covered entity insight on how to structure the bill, requested additional information from specific hospitals, and held special meetings to discuss the future of the program. At the end of the year, we have increased chaos to show for it. However, the chaos now has laid the groundwork for change. With $66.3 billion dollars of drug purchases at issue (the amount of 340B drugs purchased under the 340B program in FY2023 per a recent HRSA report) and a new administration with a keen eye to change the way we see healthcare, disruption is inevitable. Your 340B program will not look the same by December 2025. We will see an overhaul to the basic 340B qualification framework. Good or bad, best to prepare.

Rob Monroe, J.D.| President More

Patients at Home in 2025 
Increasing healthcare costs and an aging population will continue to exacerbate existing trends of patients receiving care within their homes. Telehealth, hospital at home programs, remote monitoring among other means in use or to be developed will be necessary for the continued well-being of an increasing number of patients. Most costly and inconvenient healthcare settings will see plateauing utilization as more modalities and services become acceptable and reimbursable in residential settings. Artificial intelligence coupled with remote monitoring will only increase the efficiencies already associated with remote monitoring and telehealth services. Institutional providers, ambulatory healthcare suppliers, physician groups and beyond must remain cognizant of the shift to home-based services to complement their existing services and with anticipation for new care delivery opportunities. 

Preston Sisler, J.D.| Vice President & Assistant General Counsel 
Addressing the Growing Demand for Behavioral Health Services 
There continues to be a lack of behavioral health services across the country, with some areas worse off than others. To address this issue, Advis has recently seen new investments in behavioral health services. In 2025 and beyond, look for hospitals and other providers to increase investment and focus on behavioral health services, including for facilities, staff, technology, patient initiatives, and employee well-being programs. Integration with primary care teams, creation of behavioral health urgent care services, and focus on early intervention vs. reactionary treatment are some examples of approaches designed to meet community needs.  Providers may also look to partnerships with employers or schools to provide care or augment existing programs. As the stigma surrounding behavioral health diminishes further, the need will continue to grow well beyond 2025.

Susan Maupin, J.D.| Vice President  
Expense Reduction and Growth Opportunities in 2025 
Healthcare in 2025 will bring with it a continued need for internal strategic expense reduction efforts to maintain a positive margin while also exploring growth opportunities to meet community needs. Post COVID healthcare has not bounced back to pre-pandemic status, and healthcare providers are not seeing reimbursement increases in the same trajectory that expenses have increased over the past several years. Specific reduction efforts to be addressed by providers will be with securing and maintaining core direct care staff, reducing uncompensated care loss through length of stay management, analyzing and acting upon those costs which can be reduced such as supplies, and reviewing and analyzing staff complement to ensure maximum productivity and/or staff position consolidation as appropriate. Healthcare providers will also need to look at the best growth strategies of their organization to meet community needs and maintain best financial viability. This will be challenged with the strong push for outpatient services over inpatient care, including post-acute venues, and increased denials for inpatient services by managed care organizations.   

Sylvie Brick, M.S.| Senior Consultant & Senior Data Scientist  
Increased scrutiny of CMS Hospital Price Transparency expected in 2025 
In 2025, hospitals are expected to face intensified scrutiny regarding compliance with the Centers for Medicare & Medicaid Services (CMS) price transparency regulations. This escalation is driven by a series of regulatory updates and enforcement actions aimed at enhancing the accessibility and standardization of pricing information. On January 1, 2024, CMS mandated that hospitals improve access to their machine-readable files (MRFs) by including a .txt file in the root folder of their websites and adding a ‘Price Transparency’ link in the footer of their homepages. Subsequently, by July 1, 2024, hospitals were required to adopt a CMS-specified template layout and data specifications for their MRFs, ensuring uniformity in the presentation of standard charge information. Looking ahead, effective January 1, 2025, additional data elements must be incorporated into the MRFs, including estimated allowed amounts, drug units and types of measurement, and applicable billing modifiers. These progressive requirements reflect CMS’s commitment to enforcing price transparency. 

Valerie Ford | Vice President | Enrollment
Andrea Graham | Vice President | Enrollment
Expanded Oversight for Home Health Agencies 

Starting in 2025, CMS will introduce a temporary period of enhanced oversight for new Home Health Agencies (HHAs) in an effort to further prevent fraudulent activities. The oversight period will be between 30 days and 1 year and may include, but is not limited to, prepayment review and payment caps. Additionally, the definition of a new HHA has been expanded to include facilities that are seeking to reactivate their billing privileges. If not already in place, “new” HHAs should develop a plan to review and bolster operational and billing compliance. 

Natasha Shukla, J.D.| Senior Consultant
Telehealth Rollbacks will Continue
Over the last year, we have seen CMS rollback pandemic-era flexibilities for providers granted to ensure continuity of care during a deadly pandemic in all but a few areas of patient care. Since the onset of the COVID-19 pandemic, CMS has continued monitoring telehealth usage in behavioral health and remote patient monitoring (RPM) fields. Given the increase in usage of behavioral health and RPM, coupled with the existing physician shortage especially in rural communities, expect CMS to continue expanding coverage of both types of services provided to rural patients in 2025 and beyond. For other telehealth services, however, disparate state parity laws are likely to continue inhibiting the provision of telehealth services as a whole. Misalignment in coverage policies across different payers, including Medicaid and Medicare, will also act as a hurdle for expansion beyond rural and behavioral care. As CMS continues to assess and update rules around telehealth, we recommend ensuring telehealth billing codes and procedures remain compliant with the latest guidance. 

Bryan Niehaus, J.D.| Vice President 
Provider Enrollment/Credentialing Challenges Persist 
Providers have experienced another challenging year for provider enrollment and payer credentialing in 2024, and we can expect continued challenged in 2025. High turnover in CMS MAC offices during the pandemic and the evolution of portal-based application/record requirements have contributed to ongoing complexity and lengthy review times for baseline CMS enrollments.  Delays with CMS updates ripple down the payer ladder. Coupled with diverse, byzantine, and at times purposefully challenging managed care credentialing processes imposed by payers – health systems will require subject matter expertise, organization, and dedicated resources to effectively manage enrollment and credentialing for their entities and individuals.  Organizations without experienced resources in place, will face reimbursement losses and delays in patient care where payer enrollment and credentialing gaps persist.

Frank Banfer, J.D.| Senior Consultant 
More Healthcare Leaders Need to Adopt Operational Excellence Best Practices  
Both hospital and health system operating margins are still low as compared to pre-pandemic financials. In fact, these tight margins just may be the new normal. That means new approaches to leadership and management need to occur to adapt to this new landscape. One new approach, backed by science, includes operational excellence practices. OpEx, for short, mainly relies on lean and 6-sigma practices to reduce variation and waste while improving efficiency and efficacy. What does this look like to a healthcare leader? It provides the team with a structured approach to visualizing current state performances and coaches front-line staff on how to problem solve in real time. We’ve seen impacts to an organization’s bottom line by implementing such practices. And impacts to critical patient safety initiatives. 

Ryan Yokley, J.D.| Vice President  
Advancing Mental Healthcare Post Pandemic  
During the COVID-19 pandemic, CMS expanded Medicare telehealth coverage for mental health services. Some of these efforts were limited to waivers applicable only during the public health emergency, while others have been implemented on a permanent basis; or alternatively, remain under CMS review for potential permanent implementation. As demand for mental health services continue to dramatically increase across the county, finding additional ways to increase access to mental health services, as well as providing such services in the most efficient and economical means available is paramount. Advis recently assisted one of its clients with establishing the first dedicated psychiatric emergency department in the Commonwealth of Virginia. This has significantly streamlined the hospital admission process for a specialized patient population and is aimed at reducing costs while enhancing the patient’s overall experience. Advis predicts we will continue to see implementation of such innovative endeavors with increased frequency over the next year and beyond in the area of mental health services