Rethinking open enrollment: Why plan design needs provider performance data

Image: Adobe Stock

Every fall, millions of Americans make a big decision when they choose their health plan for the year ahead. During open enrollment, employees pay closer attention to their benefits than at any other time. But while the act of enrollment gets the spotlight, the choices that matter most are those that shape cost, quality and access to care. In reality, open enrollment is an intentional combination of strategic plan design decisions before an employee ever sees their plan options.

As healthcare costs continue to rise, employers face a pressing challenge: designing plans that do more than provide coverage. They must guide members toward better care at a lower cost. The most effective path forward is embedding provider performance data into the very core of plan design, making quality and value inseparable from every member decision. 

The real cost driver: Plan design, not plan selection

Most employees don't shop for doctors during open enrollment; they shop for plans. In fact, half of employees spend less than an hour even choosing their health plan. Once enrolled, they start searching for providers only when they need care. That means the real opportunity to improve outcomes and control costs comes at the plan design stage.

When networks are built without incorporating provider performance data, employees can be unintentionally steered toward wide variation in care quality and cost. Poor-quality care drives ripple effects throughout the system: missed diagnoses, unnecessary procedures, and complications that lead to higher downstream costs for both employers and employees.

Data shows that variation across providers, even within the same specialty and geography, can account for thousands of dollars in difference per episode of care. For high-impact specialties like primary care, pediatrics and OB-GYN, that variation directly affects both short- and long-term health outcomes.

Open enrollment: The moment of leverage

By embedding provider performance insights into plan design, employers can make open enrollment a more meaningful experience. Members may not be choosing individual doctors at this stage, but they can feel confident that their plan is designed to connect them to the right care when they need it.

This reframes open enrollment from being a once-a-year administrative task into a strategic opportunity. This is where benefit leaders can ensure the plans employees are choosing from are already optimized for quality, cost and equity.

Why provider performance data is essential in plan design

For years, provider quality data was incomplete, inconsistent, or based too heavily on measures like patient satisfaction and cost. Today, access to rigorous clinical evidence and advanced analytics has changed the game. Employers and payers can now differentiate top-performing providers based on the objective measure of care quality.

The most effective frameworks for measuring performance focus on three key dimensions:

• Appropriateness — ensuring the right care is delivered at the right time.

• Effectiveness — assessing how well that care leads to positive health outcomes.

• Cost — accounting for efficiency without compromising quality.

When these insights are integrated into plan design, the impact is substantial:

• Smarter network curation, where only high-value providers are included.

• Benefits that guide members toward top-performing clinicians.

• Equitable access to proven, high-quality care across populations.

Embedding data-driven insights at the design stage creates a foundation for better outcomes and more predictable costs. It shifts the system from reactive to proactive, ensuring that plan design itself becomes a lever for both quality improvement and cost control.

From cost escalation to cost control

Healthcare costs are projected to rise again in 2026, putting continued pressure on employers and employees alike. Yet the biggest lever for cost control isn't shifting more costs to employees; it's how plans are designed and how care is delivered.

When plan design leverages provider performance data, employers can influence the system's biggest cost drivers: unnecessary care, avoidable complications, and poor outcomes. Smarter design leads to better provider access, healthier employees and lower overall spend.

It's a win-win for everyone — employers, payers and members.

Open enrollment should be more than checking a box. It's the culmination of thoughtful plan design decisions that, if done right, set employees up for a healthier, more affordable year.

For benefits leaders, that means rethinking open enrollment as a strategic moment built on a data-driven foundation. By embedding provider performance insights into plan design, organizations can ensure that quality, cost and confidence are aligned from day one.

Source: EBN