In 2026, plan sponsors face the same perennial challenge: managing rising medical costs while keeping employees engaged and satisfied with their benefits. Too often, benefits decisions—adjusting deductibles, copays, or contribution levels—are treated as isolated levers. Without an underlying architecture, these interventions behave like random patches: some employees benefit, some are frustrated, and the expected savings are inconsistent.
Health plan architecture provides a framework for designing a system that balances provider access, allowable costs, and member shared costs, while producing a predictable and confident member experience. As PwC and Mercer research consistently show, a well-structured plan not only improves financial outcomes but also enhances the employee experience, reduces friction, and makes cost-management strategies more sustainable.
The Three-Axis Model: Access, Allowables, and Member Incentives
The foundation of strong health plan architecture is a three-axis model. Every design decision should be tested against these dimensions. Access addresses whether members can realistically use a given provider or service. Are Tier 1 providers geographically dense, easy to schedule with, and well-known to employees? Allowable costs establish the target reimbursement for services and define what the plan will pay. Without clarity here, employers cannot accurately forecast costs or steer members effectively. The third axis, member incentives and experience, ensures that employees feel confident and guided in navigating their benefits. Incentives should clearly reward high-value choices without introducing confusion or frustration.
When these three axes are considered together, plan sponsors can create a predictable, measurable framework. Decisions around network design, tiering, and cost-sharing are no longer arbitrary—they are deliberate strategies that produce consistent results.
Common Architecture Challenges
Despite the benefits of an architecture-focused approach, many employers struggle with common pitfalls. Incentives may conflict with access, for example, when Tier 1 networks are cheaper but not conveniently available to employees. Incentives may also undermine the member experience if employees do not trust the cost estimates or find the pathways confusing. Finally, incentives that are too weak fail to influence behavior, while overly punitive designs risk backlash and dissatisfaction.
These challenges are more than theoretical. Mercer and PwC studies repeatedly demonstrate that poorly aligned incentives often lead to suboptimal utilization patterns and lost savings. Employers attempting to manage trend without a holistic architecture often end up with inconsistent results, frustrated employees, and unanticipated cost overruns.
Designing Tiering and Steerage That Works
Effective tiering and steerage hinge on a few core principles. Tier 1 providers must be easy to access and predictably priced for employees. Clear cost differentials should reward choosing high-value providers. Advocacy and navigation support can help members make the right choices, reducing friction. The combination of these elements ensures that employees are guided toward high-quality, cost-efficient care, rather than feeling forced or confused.
High-performance networks, centers of excellence for high-variation episodes, and direct contracting models are examples of design levers that can reinforce plan architecture. By pairing network strategy with transparent pricing and member guidance, employers can achieve sustainable cost containment without sacrificing the employee experience. PwC notes that using transparent price and quality datasets in contracting helps employers negotiate more effectively while also empowering employees to make informed choices.
Consumerism That Works
Consumerism in benefits design is often misunderstood as simply increasing deductibles or shifting costs to employees. In reality, successful consumerism focuses on clarity, predictability, and confidence. Employees should understand what is covered, how to access services, and what costs to expect. When combined with targeted incentives, consumerism encourages high-value utilization patterns while minimizing confusion.
For example, integrating decision-support tools, cost calculators, and member advocacy services can steer employees to Tier 1 providers or centers of excellence. According to Mercer, over a third of large employers are already implementing alternative medical plan designs that guide employees to high-value providers, often reducing employee out-of-pocket costs while improving outcomes.
Evaluating Designs With a Scorecard
Employers often evaluate plan changes using simple savings projections, but these can be misleading. Without a holistic lens, “savings” may come at the cost of member frustration, underutilization of care, or unexpected claims leakage. A scorecard approach ensures that every change is measured not just for cost impact but for access and experience. This method allows plan sponsors to identify false wins early, adjust design levers, and maintain a high-quality member journey.
Key scorecard elements include geographic coverage of Tier 1 providers, average allowable cost versus market benchmarks, incentive strength, and predicted adoption rates. Collecting and analyzing these metrics ensures that architecture decisions are intentional, repeatable, and defensible.
Pharmacy Integration as a Core Design Component
Pharmacy benefits, long treated as separate from core medical plan architecture, have become central to controlling trend. PwC reports that biosimilar adoption and specialty drugs—including GLP-1 therapies—significantly affect employer cost trajectories. Employers must integrate pharmacy strategy into their broader health plan architecture, using clinical criteria, step therapy, and transparent pricing models. This integration allows plans to manage cost while maintaining member access and satisfaction.
The KFF 2025 employer survey underscores this trend. Coverage decisions around GLP-1 weight loss therapies have become a major cost driver and decision point for employers, highlighting the need for coordinated architecture that incorporates medical, pharmacy, and behavioral health considerations.
Behavioral Health: Access and Affordability
Behavioral health utilization continues to rise, with PwC reporting a nearly 80% increase in inpatient claims and 40% in outpatient claims between January 2023 and December 2024. Plan sponsors need strategies that maintain access and quality while managing cost. This includes integrating EAP, carve-out, or fully integrated behavioral health models, paired with member navigation and transparency.
High-growth employers recognize that behavioral health must be considered in the same architectural framework as physical health services. Incentives, networks, and member support are all aligned to reduce gaps in care and optimize cost.
Practical Steps for Employers
To implement an architecture-focused approach, plan sponsors should begin by segmenting the population and identifying “avoidable trend” drivers. High-cost claimants—those with complex chronic conditions or significant specialty drug needs—should be targeted with explicit performance metrics for vendors and programs.
Contracting strategies should prioritize scalable, repeatable solutions. High-performance networks and direct contracting models should be curated, tied to transparent member incentives, and embedded within a clear governance structure. Price transparency and decision-support tools help employees understand choices, costs, and how to access care.
Pharmacy benefits must be tightly integrated, with GLP-1 pathways, biosimilar adoption, and transparent pricing models driving trend management. Cost-sharing adjustments should be paired with navigation support and clear communication to protect the employee experience.
Ultimately, architecture ensures that every dollar spent is aligned with a deliberate strategy, balancing cost, access, and experience. The result is sustainable savings, better utilization patterns, and more satisfied employees.
Why This Matters for UBF
UBF’s positioning as a health plan architect is strengthened by demonstrating a repeatable, measurable approach to plan design. By emphasizing architecture rather than isolated interventions, employers can see how networks, cost allowances, and incentives interact to drive trend. This approach also provides a foundation for advanced strategies, including defined contribution pathways and innovative consumerism designs, supporting both affordability and employee experience.
Employers that adopt an architecture-focused framework are better equipped to navigate the persistent cost pressures identified by PwC, Mercer, and KFF. With clear governance, integrated pharmacy strategy, and aligned behavioral health, UBF clients can achieve predictable outcomes while maintaining member confidence.
Explore how a deliberate, architecture-focused approach can improve your health plan’s cost efficiency and member experience, and take a closer look at the design principles that drive smarter decisions by viewing the Health Plan Architecture Blueprint.
