The ROI Reality Check: Why Payer-Market Fit Requires More Than Clinical Value

Demi Radeva

4 minutes ago

6 min read

Clinical outcomes, member satisfaction, and product quality remain essential to healthcare innovation. But as health plans and employers become more selective about their investments, HealthTech companies face a growing challenge: proving that their solutions deliver measurable financial value.

A solution can improve clinical outcomes, earn exceptional member satisfaction scores, and still struggle to secure or retain a payer contract.

Recent examples from the market illustrate just how much the bar for payer-market fit is changing.

One health plan ended several vendor relationships after investing significantly in implementation, particularly when vendors lacked independently validated return on investment (ROI). Another national payer paused commercial vendor partnerships for 18 - 24 months despite strong clinical outcomes and Net Promoter Scores exceeding 98. In another case, a promising solution lost a competitive opportunity because a rival had sufficient venture capital backing to subsidize the cost of the initial engagement and make the economics impossible to compete with despite an inferior product.

Each situation reveals a different financial consideration shaping payer purchasing decisions:

The first highlights the importance of validating ROI to maintain existing relationships.
The second demonstrates how budget constraints and shifting priorities can override strong clinical performance.
The third shows how pricing and financial flexibility can influence competitive outcomes, even when one solution may offer greater value.

Together, these examples illustrate why clinical outcomes and member satisfaction, while essential, are not enough to secure payer adoption. HealthTech companies must also demonstrate credible financial returns, align with buyer priorities, and understand the economics influencing purchasing decisions.

The Changing Economics of Payer-Market Fit

Health plans evaluate solutions within a complex environment of budget constraints, existing vendor relationships, internal capabilities, and evolving organizational priorities.

A solution may address a meaningful clinical need without aligning with an available budget or a payer's immediate strategic priorities. Even when the value proposition is compelling, buyers must determine whether the expected impact justifies the investment compared with other available options.

This creates several important considerations for HealthTech companies:

Budget alignment: Does the solution address a priority with an identifiable funding source?
Financial impact: Can the vendor demonstrate measurable savings, cost avoidance, or another economic benefit?
Competitive alternatives: How does the solution compare with existing vendors, internal programs, or other approaches?
Implementation economics: How quickly can the buyer expect to realize value, and what resources are required?
Evidence and validation: Can the projected outcomes withstand independent review?

These questions are becoming central to commercialization conversations.

For founders, understanding payer-market fit means evaluating whether the solution addresses a problem that buyers are both motivated and financially positioned to solve.

Enterprise Buyers Are Raising the Stakes with Performance-Based Contracts

The Peterson Health Technology Institute's (PHTI) 2026 State of Digital Health Purchasing report provides additional insight into how health plans and employers are evaluating digital health investments.

The report found that:

55% of health plans are using performance-based contracts for digital health solutions.
68% of employers are using performance-based contracting arrangements.
85% of buyers using these arrangements put at least 25% of vendor fees at risk.

These findings suggest that buyers increasingly want vendors to share accountability for the outcomes they promise.

Performance-based contracts connect some portion of vendor compensation to agreed-upon results. Depending on the solution and buyer, these outcomes may include clinical improvements, utilization changes, financial savings, or other measurable performance indicators.

For HealthTech companies, this changes the role of ROI in the sales process.

A financial model showing projected savings may help establish initial interest. But buyers also need confidence that those savings are achievable, measurable, and attributable to the solution.

The conversation is shifting from what a solution could deliver to what a vendor can credibly demonstrate and stand behind.

Independent ROI Validation Matters

Many HealthTech companies develop ROI models using clinical studies, industry benchmarks, pilot results, or assumptions about future utilization.

These models can provide a useful starting point, but their credibility depends on the quality of the underlying evidence.

A decade ago, a literature-based ROI calculator using published research and estimated savings could be enough to initiate a payer conversation. Today, buyers are setting a much higher bar. Rather than relying solely on projected outcomes, they increasingly expect solution-specific evidence demonstrating measurable results with other health plans, self-funded employers, or enterprise buyers.

For example, a company claiming its solution reduces avoidable emergency department visits may use published research to estimate potential savings. But a prospective payer will want to see whether the solution has actually reduced utilization and spending in a comparable population, how those results were measured, and whether the financial impact can be independently validated.

That evaluation requires answering several questions:

Population: Which members are expected to benefit, and how representative are they of the payer's population?
Baseline: What would utilization and spending look like without the intervention?
Effect size: How much improvement can reasonably be expected?
Attribution: How much of the observed impact can be connected to the solution rather than external factors?
Timeframe: When will the financial benefits materialize?
Measurement: What data and methodology will be used to validate the results?

Without clear answers, even an impressive projected ROI can be difficult for buyers to trust.

Third-party actuarial validation can help strengthen the financial evidence behind a solution by independently evaluating assumptions, methodologies, and projected economic outcomes.

It can also help companies identify weaknesses in their value proposition before those concerns emerge during payer discussions.

Importantly, validation does not guarantee that projected savings will materialize. Its value lies in making the economic case more transparent, defensible, and relevant to the buyer's decision-making process.

The Competitive Advantage of Financial Readiness

The growing emphasis on measurable ROI has implications beyond contract negotiations.

It can influence which companies gain access to pilots, advance through procurement, secure partnerships, and maintain relationships when payer priorities change.

Consider two vendors offering similar clinical benefits.

One presents strong outcomes and a projected savings model. The other provides comparable evidence alongside an independently reviewed financial analysis, a clear measurement framework, and a proposed performance-based contract.

The second vendor may be better positioned to address the buyer's financial concerns and reduce uncertainty around the investment.

This is particularly important for early-stage HealthTech companies competing against established vendors or well-capitalized startups that can offer discounted pilots or subsidized implementation.

Founders may not be able to compete on price alone. But they can strengthen their position by demonstrating a credible understanding of the buyer's economics, expected return, and implementation requirements.

Financial readiness is becoming an important component of competitive differentiation.

A Practical ROI Reality Check for HealthTech Founders

Before presenting a 3x, 5x, or 10x ROI claim to a prospective payer or employer, consider one question:

If the buyer asked you to put 25% of your fees at risk against the outcomes in your ROI model, how confident would you feel?

If the answer is very confident, the next step is making sure your assumptions, supporting evidence, and measurement methodology are clearly documented.

If the answer is uncertain, that hesitation may reveal an opportunity to strengthen your model.

Review the assumptions driving your projected savings. Identify which outcomes have been independently demonstrated and which depend on future performance. Consider whether the model reflects the target buyer's population, reimbursement arrangements, and operating environment.

This exercise can help founders distinguish between an attractive value proposition and one that is ready for serious payer evaluation.

It also provides a foundation for more productive discussions about pricing, contracting, and shared accountability.

Building a Stronger Business Case for Payer Adoption

Health plans and employers continue to invest in healthcare innovation, but their purchasing decisions increasingly require a clearer connection between clinical impact and economic value.

For HealthTech companies, this creates an opportunity to approach commercialization with greater financial discipline.

A strong payer-market fit strategy should establish who benefits from the solution, who pays for it, what financial or operational outcomes matter to that buyer, and how those outcomes can be measured.

Clinical evidence creates an important foundation. Economic evidence helps translate that value into a purchasing decision.

As performance-based contracting becomes more common, companies that can validate their ROI assumptions, demonstrate financial impact, and align their value proposition with buyer priorities will be better prepared for increasingly selective purchasing environments.

The question is no longer simply whether a HealthTech solution can deliver meaningful value. It's whether that value can be demonstrated, measured, and supported by an economic case that buyers trust.

Strengthen Your ROI Story with Akros Advisory

A compelling ROI model can open the door to payer conversations. A credible, independently validated financial case can help move those conversations toward adoption.

Akros Advisory helps HealthTech companies strengthen their commercialization strategies by connecting clinical value with payer economics, buyer priorities, and measurable financial outcomes.

Through our actuarial expertise and payer strategy experience, we help founders evaluate ROI assumptions, build more defensible economic models, and prepare for the financial questions that shape purchasing decisions.

Ready to put your ROI claims to the test? Connect with Akros Advisory to strengthen your business case for payer adoption.

Source: Peterson Health Technology Institute, 2026 State of Digital Health Purchasing.