Cost of Care

Cost-of-care pressure is sharpening around utilization management and specialty spend: Centene is joining “gold card” prior authorization waivers for top-performing providers as states and the Trump administration push PA reform, creating a near-term opening for ACOs and high-quality groups to convert performance data into lower administrative burden and faster access (Healthcare Dive). At the same time, pharmacy and referral management are moving deeper into value-based contracting, with pharmacy payment models tying reimbursement to quality rather than volume and Privia NT reporting a 45% referral-cost reduction tied to ACO/MIPS performance improvement—evidence that downstream network steerage and drug-spend accountability are becoming core VBC cost levers. Medicaid work requirements and ACA subsidy integrity actions by the Trump administration add coverage-continuity risk and enrollment churn, especially for disabled SSDI applicants awaiting Medicare, which could disrupt population health management and shift uncompensated or poorly coordinated care back onto providers (KFF).