Strategic Investment Priorities for Healthcare Payers
CMS What strategic investments should healthcare organizations prioritize in the coming year? According to a comprehensive Gartner survey of 46 US payer leaders, four critical initiatives dominate the healthcare landscape: quality improvement programs, advanced data and analytics capabilities, behavioral and mental health services expansion, and risk adjustment optimization strategies.
However, the survey revealed a compelling insight: regulatory shifts emerged as the primary driver influencing enterprise decision-making across all organizations. This regulatory factor stood alone as the only consideration deemed at least “somewhat important” by every single respondent, with nearly three-quarters of surveyed leaders rating it as “very important” to their strategic planning processes.
Regulatory Compliance as Strategic Opportunity
Healthcare organizations traditionally view regulatory compliance as a necessary burden that diverts resources from “more strategic” organizational priorities. This perspective, while understandable, overlooks a critical opportunity. When properly aligned, regulatory mandates can provide the catalyst and urgency needed to advance essential business initiatives that might otherwise languish due to competing priorities or resource constraints.
Smart healthcare leaders recognize that new regulatory requirements, when approached strategically, create opportunities to establish robust infrastructure and streamline business processes that strengthen organizational capabilities for years ahead. The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), released in January 2024, exemplifies this transformative potential for healthcare payers.
Understanding CMS-0057-F Interoperability Requirements
The CMS-0057-F rule represents a pivotal milestone in a broader regulatory movement requiring substantial information technology investments to democratize data-driven healthcare decision-making and accelerate the transition to value-based care delivery models.
Historical Context of Healthcare Data Regulation
This regulatory evolution began in 2009 when the HITECH Act digitized and standardized provider electronic health record (EHR) data across the healthcare ecosystem. The journey continued in 2020 with CMS-9115-F, which introduced API-based information sharing requirements for payers. Most recently, in 2025, HTI-4-F established new certification criteria and related standards for the ONC Health IT Certification Program, including critical updates for electronic prior authorization workflows.
Core Mandate: FHIR-Based API Implementation
CMS-0057-F mandates that payers support digitized data utilization and FHIR-based APIs to advance interoperability among all healthcare stakeholders while automating previously manual and costly prior authorization processes. Although the rule specifically targets federally funded “impacted payers,” industry experts anticipate significant ripple effects throughout the entire healthcare sector, influencing both public and private payer operations.
Four Core Information Sharing Mandates
While the rule’s name emphasizes interoperability infrastructure, successful compliance demands far more than a simple IT implementation project. Deploying the mandated APIs requires addressing numerous operational, policy, and workflow decisions—all critical to maximizing return on infrastructure investments.
CMS-0057-F specifically addresses four distinct categories of information sharing for impacted payers:
1. Payer-to-Payer Information Exchange
Sharing comprehensive member information with both impacted and non-impacted payers enables the construction of longitudinal member records that facilitate superior care coordination across the healthcare continuum.
2. Member and Representative Access
Providing members and their authorized representatives with direct access to health information empowers them to better manage and coordinate their own care, promoting patient engagement and informed decision-making.
3. Provider Information Sharing
Sharing relevant clinical context and care team visibility with in-network, treating providers ensures they have complete awareness of patient clinical history and current care coordination efforts.
4. Prior Authorization Automation
Facilitating seamless information exchange between providers and payers streamlines the determination of prior authorization requirements and expedites decision-making processes, reducing administrative burden for all parties.
Building Longitudinal Health Records
These four information sharing mandates collectively build upon and support investment in robust longitudinal health record infrastructure. The rule’s implicit requirement for deploying or expanding longitudinal health records capable of integrating member clinical data, claims information, and social determinants of health represents one of the greatest opportunities to advance organizational priorities including quality improvement, advanced analytics, and risk adjustment optimization.
As noted by IDC’s Jeff Rivkin, well-documented barriers between the “claims side of the house and the care side of the house” become particularly evident in prior authorization workflows. An effective compliance strategy for the CMS final rule suggests that payers must unify their organizations and systems around comprehensive member longitudinal health records.
Breaking Down Data Silos
Fundamentally, the healthcare industry must dismantle the clinical and administrative data silos that have proliferated throughout US healthcare for decades. Only by achieving true interoperability can healthcare realize the dramatic quality and efficiency improvements that other industries have achieved through seamless data integration and information sharing.
CMS-0057-F provides a powerful vehicle for driving this essential transformation. The rule requires investment in, contribution to, and utilization of longitudinal or unified care records necessary to automate burdensome manual processes and generate actionable insights that improve care delivery and promote wellness at the optimal point in time and care setting.
Implementation Strategy and Team Alignment
Ensuring your regulatory compliance investment delivers broader organizational returns beyond mere compliance requires coordinated team effort. Successful implementation demands close alignment among information technology leadership, clinical operations teams, and business strategists, all guided by regulatory compliance expertise. This cross-functional collaboration ensures that infrastructure investments serve immediate compliance needs while building sustainable competitive advantages for the future.
Organizations that view CMS-0057-F as merely a compliance checkbox miss the strategic opportunity to fundamentally transform their data infrastructure, care coordination capabilities, and member experience—investments that will pay dividends long after compliance deadlines pass.
Discover the latest payers’ news updates with a single click. Follow DistilINFO HealthPlan and stay ahead with updates. Join our community today!
