The US healthcare landscape is shifting towards payers managing care actively rather than just paying for claims submitted by providers. Medicare Advantage and managed Medicaid are examples of this change, with payers making care decisions using mechanisms like prior authorization and case management. The challenge now is how payers will navigate contradictory incentives in the future. Data and software tools will play a crucial role in combining clinical and financial data to enable payers to shop for value in healthcare. The CMS Interoperability and Prior Authorization Rule is a key development in this transformation, requiring payers to organize their data and make it accessible to patients and providers.
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Putting Payers in the Driver’s Seat: How the New CMS Interoperability and Prior Authorization is Changing Healthcare
