Top trends in utilization management

Trend 1: Streamlining prior authorizations

Prior authorization PA is one part of utilization management that ensures prescribed healthcare services are appropriate and evidence based.

In response to calls to make PA more efficient, recent legislative efforts have been introduced to streamline the process. In January 2024, the Centers for Medicare & Medicaid Services (CMS) released the Interoperability and Prior Authorization Final Rule, mandating new processes to improve PA, like faster turnaround times for PA decisions and the adoption of common technology across providers and health plans to enable a more efficient process.

Carelon’s vision: Proactive preparation. We are already compliant with many aspects of the CMS final rule today. For example, we've already implemented CMS' required technology to facilitate data exchange between payers. Today, 93% of the requests we receive are closed within 48 hours — thanks in part to this technology. Read more in our blog article  by Dr. Katherine Dallow, Vice President and Executive Medical Director of Government Strategy at Carelon Medical Benefits Management. 

Trend 2: Integration of electronic medical records

To further support a streamlined PA infrastructure, innovative organizations are working to scale their ability to integrate PA services with provider electronic medical records (EMRs). This eliminates the need for manual uploads of clinical records, driving faster — and often real-time — PA approvals.

Carelon’s vision: Immediate integration. At Carelon, we’re on a mission to deliver a better PA experience for you and your providers to ensure members receive quality, evidence-based care.

EMR integration benefits the healthcare system at large through enhanced data accessibility. Additionally, it offers a better provider experience by reducing the administrative burden for manual PA, which leads to faster PA submissions and decisions. This enables providers to spend more time caring for patients.

Trend 3: A member-centered approach

According to the U.S. Centers for Disease Control and Prevention, 90% of the nation’s $4.5 trillion  in annual health care expenditures are attributed to patients with chronic and mental health conditions. How can we better address the needs of high-risk, high-cost members? We take a member-centered approach. Carelon works collaboratively with providers to determine the right care and the best clinical practices. By aligning care decisions with the latest medical evidence, we're reducing total cost of care for members with complex and chronic conditions.

Carelon’s vision: Evidence-based insights. Research and reporting can provide valuable insights to identify high-risk members, determine when care requires intervention, and pinpoint treatments that are unnecessary or harmful. From there, targeted member engagement and wraparound support — including digital tools and personalized outreach — can be used to reduce ER visits, increase medication adherence, enhance member satisfaction, and lower total cost of care. We do this through programs such as Cancer Care Engagement, which leverages predictive analytics to identify members at risk of cancer, helping them navigate the cancer care journey by providing access to clinicians and key resources.

Trend 4: Contracting for outcomes

The fee-for-service model can incentivize physicians to increase the number of services they provide, regardless of whether they are clinically necessary or benefit the member. It can also lead to fragmented, inefficient care, which drives up the overall cost of healthcare.  

Value-based care favors high-quality care, which rewards providers based on improvements in clinical outcomes.

Carelon’s vision: Deliver value-based specialty care. We see value-based care advancing beyond primary care to further improve health outcomes. Transparent, detailed, risk-based models can help health plans get a more in-depth view of the utilization and costs associated with top specialty cost drivers, including oncology, musculoskeletal, and serious mental illness. Data shows the value-based care model delivers:

• Better and more equitable access to care.
• A connected member journey.
• Increased provider and member satisfaction.
• Greater affordability.