Cost & Utilization Management

Cost and utilization management activity is concentrating around two competing VBC strategies: tighter administrative controls in Medicare and more clinically integrated specialty models that take accountability for avoidable spend. Congressional pushback against CMS’s Medicare AI prior authorization pilot signals a rising political constraint on using automation as a utilization-management lever, even as MA penetration reaches 55% of eligible beneficiaries in 2026 and payers continue to rely on managed-care tools to control cost growth. At the same time, specialty VBC models such as Blue Cross NC’s Advanced Kidney Care program and Oshi Health’s GI model are positioning risk-aligned, condition-specific partnerships as a less adversarial path to reducing hospitalizations, procedures, and total cost of care through earlier intervention and longitudinal management (Blue Cross NC kidney care case study; Medicare AI prior authorization pushback).