Healthcare's Future Depends on Shifting Beyond From Prior Authorization

Prior authorization has become healthcare's most counterproductive process—consuming 45 authorization requests per physician weekly while generating more administrative costs than medical savings. This isn't a system that needs improvement; it's a system that needs retirement for the sake of providers and the patients they serve.

The solution is a paradigm flip: retire prior authorization as the default approach and make managed, provider-led utilization management the new baseline for healthcare cost and quality control. This shift creates a new standard where evidence-based practice and real-time transparency become the norm, eliminating administrative friction and care delays for patients, physicians, and payers alike. In this improved model, prior authorization becomes the exception—reserved only for the small minority of providers who haven't demonstrated consistent adherence to clinical standards, ensuring patient care is not delayed by default.

Why Precision Utilization Management Should Be the New Baseline

In the shift toward value-based care, payers succeed when providers deliver high-quality, appropriate care. The current utilization management paradigm is fundamentally misaligned with this reality—it treats all providers as potential problems rather than recognizing that most physicians consistently deliver evidence-based care.

The economics are compelling: most prior authorization requests eventually get approved anyway. We're subjecting the entire healthcare system to administrative burden, and patients to frustrating, often harmful, delays in care, to catch the minority of cases that truly warrant intervention. This is counterproductive when the goal is to reward value and improve the patient experience.

The paradigm should be inverted entirely: Start with managed utilization management as the baseline, where providers operate under transparent, evidence-based performance frameworks with continuous monitoring and feedback. This isn't about eliminating oversight—it's about making oversight intelligent and proportional to risk. High-performing providers earn autonomy through demonstrated competence, which translates directly to faster, more efficient care for their patients. Struggling providers receive intensive support and, if necessary, traditional prior authorization until they improve.

The Strategic Benefits of This Baseline Shift

The strategic benefits of this baseline shift extend beyond immediate cost savings and profoundly impact the patient experience:

• System-Wide Efficiency: When managed UM becomes the norm, administrative resources focus on genuine outliers rather than processing routine requests from trusted clinicians. This dramatically improves the return on investment for utilization management programs and, most importantly, accelerates patients' access to necessary care.
• Provider Partnership: Starting with trust creates collaborative relationships rather than adversarial ones. This collaborative spirit directly benefits patients, who experience a more seamless, trusting, and less stressful healthcare journey as physicians become partners in managing population health rather than opponents in a bureaucratic battle.
• Accelerated Innovation: When high-performers have clinical autonomy, they can rapidly adopt evidence-based innovations without waiting for policy updates. This accelerates the translation of research into practice, meaning patients get access to the latest effective treatments sooner. ‍
• Quality Improvement: Continuous performance monitoring with real-time feedback creates learning healthcare systems that improve organically. This leads directly to better clinical outcomes and higher patient satisfaction.

The Gold Card Failure Pattern

Despite these compelling advantages, most gold carding initiatives fail to achieve meaningful impact, leaving patients and providers stuck in the same frustrating cycle. Five failure patterns emerge consistently:

1. ‍The Opacity Problem: Too many gold card programs operate like black boxes, destroying the behavioral incentives that make gold carding effective. This opacity leaves patients with uncertainty and anxiety about whether their care will be approved in a timely manner. ‍
2. Narrow Scope, High Barriers: Many programs start with such limited scope or stringent requirements that they ensure minimal impact on overall administrative burden. As a result, the vast majority of patients and their physicians see no relief from the frustrations of prior authorization. ‍
3. The Cost Fear Factor: Internal stakeholder concerns about utilization spikes often sabotage program effectiveness. When fearful payer teams restrict programs, they reintroduce care delays and uncertainty for patients who had briefly experienced a more streamlined process. ‍
4. Cultural Resistance to Differentiation: Implementing gold carding challenges decades of uniform utilization management policies. This cultural friction often relegates gold carding to pilot status, preventing a widespread positive impact on patient access and experience. ‍
5. Process Improvement Over Structural Change: The biggest strategic error is treating gold carding as a supplement to, rather than an alternative to, prior authorization entirely. This mindset fails to deliver the fundamental transformation needed to alleviate patient burdens at scale.

The Precision Utilization Management Solution

The path forward requires moving beyond traditional gold carding toward a platform-based approach that addresses each failure pattern systematically and places patient benefit at the forefront.

• ‍Transparency Through Data: Effective programs provide continuous visibility into performance metrics and real-time feedback. This reduces the anxiety and uncertainty common in today's system for patients awaiting care. Providers should never guess about their standing or wonder how to improve. ‍
• Precision Accountability: Rather than broad approval rate thresholds, managed UM evaluates specific clinical decisions against evidence-based standards of care. This precision ensures patients receive appropriate, high-quality care without unnecessary administrative hurdles. ‍
• Proactive Risk Management: Instead of fearing utilization increases, managed programs monitor outcomes continuously. This "trust but verify" approach maintains cost discipline while preserving the efficiency gains and patient benefits—like faster access to care—from reduced prior authorization.

The Inevitable Paradigm Shift: From Exception to Standard

Healthcare organizations that establish managed utilization management as their operational baseline will define the future of healthcare cost and quality control. They'll attract high-performing providers, improve patient satisfaction through streamlined care delivery that eliminates frustrating delays, reduce administrative waste that drives up patient costs, and generate superior clinical outcomes.

Beyond operational benefits, this model creates powerful network strategy and product design opportunities that directly appeal to patients. Organizations can develop tiered product offerings that align network access with utilization management sophistication. This creates clear value differentiation, allowing patients to choose health plans that prioritize their time and well-being by guaranteeing streamlined care delivery.

Organizations clinging to prior authorization as their default operating model will find themselves increasingly obsolete as the industry, driven by provider burnout and patient demand, moves toward performance-based utilization management. The question isn't whether this shift will happen—it's whether your organization will lead it or struggle to catch up.

For healthcare executives committed to sustainable success, the imperative is clear: retire prior authorization as your default approach. The organizations that make this transition proactively will shape tomorrow's healthcare system—one where clinical competence is assumed, excellence is systematically supported, and administrative barriers that delay patient care exist only where truly necessary

Healthcare executives face a fundamental choice: continue investing in a failed prior authorization system that wastes billions annually, or embrace the paradigm shift toward managed, provider-led utilization management as healthcare's new standard operating model.

Prior authorization has become healthcare's most counterproductive process—consuming 45 authorization requests per physician weekly while generating more administrative costs than medical savings. This isn't a system that needs improvement; it's a system that needs retirement.

The solution is a paradigm flip: retire prior authorization as the default approach and make managed, provider-led utilization management the new baseline for healthcare cost and quality control.

Instead of operating from a place of universal distrust, we should start from the foundational principle that most physicians are motivated to deliver high-quality, appropriate, and evidence-based care to their patients. ^[1] When given the chance to lean into this commitment with a distinct benefit—relief from prior authorization—we can catalyze a market shift. This shift creates a new standard where evidence-based practice and real-time transparency become the norm, eliminating administrative friction and care delays for patients, physicians, and payers alike. In this improved model, prior authorization becomes the exception—reserved only for the small minority of providers who haven't demonstrated consistent adherence to clinical standards.