Health IT & Interoperability

CMS is tightening the operational infrastructure for value-based care by pushing payers toward more transparent, FHIR-enabled prior authorization processes across Medicare Advantage, Medicaid managed care, ACA marketplace plans, and state Medicaid/CHIP programs—raising the bar for plans and risk-bearing providers that depend on timely utilization management data and reduced administrative friction (HFMA). At the same time, NCQA is accelerating the move from claims/hybrid quality reporting to digital, person-centered measurement, with HEDIS MY 2027 adding person-centered outcome measures for D-SNPs and C-SNPs and moving Transitions of Care toward ECDS reporting—signaling that VBC performance will increasingly hinge on interoperable clinical data, care-plan documentation, and patient-reported goals rather than retrospective claims alone (NCQA). Together, these shifts create a strategic tension for ACOs, MA plans, and Medicaid managed care organizations: interoperability investments are becoming table stakes for both payment-model execution and quality performance, but implementation burden will fall unevenly across provider networks with variable EHR, FHIR, and analytics maturity.