Would You Sign a Multi-Million Dollar Deal Without Running the Numbers First?

In 2025, health plans are under more pressure than ever.

Utilization is climbing. Pharmacy costs are accelerating. CMS benchmarks are shifting. State Medicaid programs are embedding new requirements into every RFP. And premium growth? It’s not keeping up.

Yet many plans are still relying on upside-only contracts to navigate this landscape, a strategy that leaves them financially exposed and flying blind.

These arrangements may feel low risk, but they offer no protection when performance turns and provide little visibility into emerging cost drivers. In today’s environment, those blind spots can quietly cost millions before anyone notices.

The question isn’t whether risk is coming. It’s whether you can see it early enough to act.

The Risk You’re Carrying May Be Bigger Than You Think

On the surface, your value-based contracts may look fine: settlements are on track, quality scores are trending upward, and shared savings programs have expanded.

But those metrics don’t always tell the full story.

Behind the scenes:

• Utilization is surging in high-cost categories like behavioral health, chronic conditions, and ED visits.
• Pharmacy spend is outpacing premium revenue, driven by specialty drugs and novel therapies.
• CMS and Medicaid benchmark shifts can transform solid performance into unexpected loss.
• Contract terms are often misaligned with how providers actually operate.

Meanwhile, upside-only contracts provide a false sense of security. They delay accountability, limit your ability to course-correct, and offer no cushion when margins tighten.

By the time settlements reveal margin loss, the opportunity to course-correct is gone. The damage is already built into the results, and the cycle repeats year after year.

The Impact in Practice

Health plans that have adopted proactive modeling and real-time performance monitoring are uncovering hidden margin leakage and recovering millions of dollars that might otherwise have been lost at settlement.

It’s Not About More Data. It’s About the Right Visibility.

More spreadsheets, dashboards, or retrospective reports won’t solve this. Health plans already have data, often too much of it. The real challenge is that the data is fragmented, backward-looking, and rarely structured to answer the most critical questions:

• Where are we exposed right now?
• How will utilization and benchmark shifts affect us six months from now?
• Which contracts will quietly erode margin if we don’t act?

What plans need is forward-looking visibility into the financial trajectory of every contract before signing and throughout the performance year. This kind of insight allows you to intervene when it matters, not months after the fact.

That’s where SpectraMedix comes in. We give health plans a full lifecycle view of value-based contract performance. Not just what happened, but what’s happening now and what’s likely to happen next.

1. Model Contracts Before They’re Signed

Simulate performance under real-world scenarios using your own data:

• Adjust MLR targets, pharmacy trends, or stop-loss levels and see financial impact
• Test changes to quality measure weights, risk adjustment, or population mix
• Compare side-by-side scenarios to find terms that protect margin

The Value Add: You enter negotiations with confidence, not assumptions.

2. Forecast Utilization and Quality Trends

Cost pressures build gradually. SpectraMedix helps you anticipate:

• Which provider groups are trending toward underperformance
• Where utilization spikes are likely to occur
• Which quality domains are slipping and how they’ll impact payouts

The Value Add: Your teams can act before problems affect your bottom line.

3. Equip Providers to Act, Not React

Your providers are expected to perform in a value-based world, but most lack timely, actionable data.

We push contract-specific insights directly to your network:

• Real-time care gap lists and utilization trends
• Targeted performance summaries
• Role-based access for PCPs, care managers, and leadership

The Value Add: This isn’t passive reporting. It’s targeted enablement that drives results.

4. Reduce Disputes and Accelerate Settlement

Delays and disputes drain time and erode trust. With transparent, standardized performance data, you can:

• Track results by TIN, NPI, and contract in real time
• Ensure all stakeholders work from the same source of truth
• Resolve disagreements with clear audit trails

The Value Add: Fewer surprises. Faster resolutions. Stronger relationships.

Real Results in Action

Health plans using SpectraMedix have identified financial blind spots early and recovered millions of dollars in potential losses through better contract modeling, proactive performance monitoring, and timely interventions.

Why This Matters Now

The clock is ticking. CMS has set its sights on 100 percent value-based care participation by 2030. States are embedding shared-risk models and Social Drivers of Health funding requirements through One Big, Beautiful Bill (OBBB) and similar Medicaid reforms. These changes are moving from pilot programs to contractual mandates quickly.

At the same time, plans that are building this kind of infrastructure today are positioning themselves to manage risk with confidence as VBC accelerates. Standing still isn’t neutral. It’s falling behind.

Before You Sign the Next Contract, Ask Yourself:

• Have we modeled this contract under multiple scenarios?
• Do we know how benchmark shifts could affect performance?
• Are our providers equipped to act on performance gaps in real time?
• Do we have visibility into our downside risk?

If any answer is “no,” that contract could become a liability.

SpectraMedix Gives You the Infrastructure to Manage Risk with Confidence

We help health plans:

• Move from upside-only to shared risk with clarity
• Model contracts before signing
• Forecast performance while action is still possible
• Enable providers to deliver outcomes that protect your margins

Are your contracts set up to protect your margins?

Visit our resources page to see how SpectraMedix is helping health plans step into the future of value-based contracting.