The No Surprises Act IDR portal is not the only avenue of dispute between payers and providers. Looking at the state of contract negotiations, payer-provider relations may have never been more contentious. The last quarter of 2025 saw a record 83 public media reports of health systems or physician groups threatening to terminate a specific payer contract, more than half of which were for Medicare Advantage (MA) plans. The prevalence of these disputes (or at least of their coverage) has increased substantially every year since 2022, as margin pressure for both payers and providers has ratcheted up the negotiating stakes. Not every instance of a reported dispute led to a contract term, and even when contracts lapse, such as with Mount Sinai-Anthem and Memorial Hermann-BCBS, it may only be for a few months. However, these episodes are still disruptive to patient care and a clear sign of a dysfunctional system. 
 
For MA plans, the heart of the issue is usually excessive prior authorizations and utilization management, which payers claim to have made progress on walking back, but it is too soon to say if that will last or turn down the temperature of negotiations. Meanwhile, Medicaid cuts will make commercial cross-subsidies all the more vital for health systems, giving contract negotiations with commercial payers an existential bent for health systems. Under these conditions, we have strayed especially far from the promise of value-based care, where health systems, payers, and patients all share incentives and benefit from positive outcomes.