Top 5 payer and PBM priorities from AMCP 2026: Focusing workflows on balancing efficiencies, volumes, and precision

2. Real world evidence is expected, but context and accountability still matter

Across sessions, speakers highlighted a mounting imperative for payers to make faster, defensible coverage, formulary, and utilization decisions — even as therapy complexity grows and governance around AI and automation tightens. This creates a tension between operational efficiency and defensible decision-making.

That tension was most apparent in the many discussions surrounding diabesity medications (GLP-1s) and balancing their potential health outcomes with new indications and financial concerns. Market drivers can’t be the overriding factor in decision-making for complex medications like these — payers and PBMs are looking for more rigorous research to support coverage decisions.

Real world evidence (RWE) is increasingly expected to inform coverage and formulary decisions. With the power of AI, more can be done with new datasets. As one session noted, real-world evidence is no longer just about evidence synthesis. It’s now about generating the analyses and evidence to back decision-making.

But more data does not automatically mean better decisions. Without clinical context, RWE can create noise instead of clarity. Speed without confidence increases risk. Payers and PBMs need decision support and medication intelligence grounded in trust and evidence to contextualize RWE. Importantly, those tools and data must support consistency as they move from policy to execution. AMCP supports this perspective to the degree that they are offering their members further training in RWE fundamentals.

3. Governance is more than a safeguard as trust becomes a competitive advantage

Trust — in data, logic, and partners — stood out as a defining influence on payer adoption and scale, whether healthcare businesses were focused on AI-driven solutions or utilization management strategies.

The quality and transparency of data is essential to driving all activities related to precision delivery of services and managing volume. In a diversifying spectrum of emerging healthcare technology solutions, payers and PBMs are gravitating toward partners who can demonstrate responsible data governance to help reduce risk, improve defensibility, and support long-term confidence. Structured, evidence-based data also provides guardrails that support responsible automation and help AI appropriately augment decision-making.

As data professionals say, “garbage in, garbage out.” If your data is not clean, if it's not well-defined, if you don't know what's in it nor properly maintain it, then instead of helping manage complexities in healthcare delivery and driving smart coverage, it may ultimately undermine your decision-making and efficiencies.

4. Interoperability: Continuity across medication therapy and care transitions

Even with the cleanest data and most trustworthy solutions and governance, payers won’t be able to adequately address workflow efficiency and complex care without interoperability. Health plans and PBMs need to be able to communicate across the value chain and get the timing right.

As an example, when a patient transitions from a hospital to a long-term care facility (LTC) on a tightly managed medication regimen, coordination across providers, health plans, and the receiving facility is essential to ensure medications are approved and available at the point of care. Without that interoperability between systems, delays can occur — raising the risk of readmissions, adverse events, and poor patient outcomes.

When these failures occur, they often stem from information gaps, not lack of intent. Interoperable, trusted medication intelligence and clinical knowledge help reduce friction across care settings, and shared reference points support coordination between providers, pharmacists, and payers.

5. Clinical complexity and specialty drugs demand tighter drug and medical alignment

The intensity of the complex nature of specialty drug treatment regimens was of great concern for many conference attendees. From oncology and rare disease to new approaches for managing chronic conditions, sessions repeatedly underscored that diagnostics, treatment selection, and medication management can no longer be treated as separate decisions.

It’s getting more expensive to treat patients with specialty therapies, but in some cases, without them, members face catastrophic health issues. So, it becomes even more important to get the right drug at the right dose, at the right place, at the right time, to the right person and with the right provider.

Misalignment between clinical decision-making and pharmacy policy leads to:

• Delayed access
• Inappropriate utilization
• Higher downstream costs

Payers and PBMs are still figuring out how to better connect clinical evidence, diagnostic insights, and medication intelligence so decisions that cross multiple benefits teams are coordinated rather than siloed.

Payers and PBMs don’t need more technology, they need purpose-built solutions

AMCP 2026 made one thing clear: As managed care grows more complex, payers and PBMs don’t need more technology — they need more trusted foundations for decision-making. Clinical evidence and medication intelligence will play an increasingly central role in helping organizations move faster, act responsibly, and confidently navigate what comes next.

Speak to a specialist to see how payer and digital health tech solutions from UpToDate® and Medi-Span® can help you tackle these challenges and reach operational efficiency and data quality goals.