Health plan executives struggle to realize more effective utilization management programs due to pervasive abrasions throughout the process, lack of comprehensive data analytics, and an overreliance on one-size-fits-all policies rather than holistic management of utilization across a member’s care journey. Evolving utilization management requires plans to mature across four key domains: programmatic vision and enterprise integration; data exchange and technology infrastructure; program execution; and performance on access, outcomes, cost, and quality.

Programmatically, the future of utilization management is:

• Impact-driven, focusing UM activities only where there is proven value, balancing standardization and adaptability across unique plan-provider relationships and member needs.
• Less reliant on prior authorization as its main lever — via increased transparency of UM requirements, criteria, and outcomes — and better integration with both plan and provider care management.
• Less abrasive for providers and consumers as a result of increased collaboration with, and integration between, plans and providers.
• More efficient and less resource intensive for plans through bi-directional data integration and the adoption of advanced technology such as artificial intelligence (AI) and machine learning.