Beyond Prior Authorization: The Strategic Shift Health Plans Can’t Afford to Ignore

Market Report | Independent Research by Sage Growth Partners

Health plans are facing intensifying pressure to improve quality outcomes while protecting margins—all amid tightening regulation, rising member expectations, and growing administrative complexity. Traditional cost‑control tools like prior authorization are no longer enough on their own.

This independent market report, commissioned by PointClickCare and conducted by Sage Growth Partners, reveals where today’s care management strategies are breaking down—and where health plans have the greatest opportunity to drive measurable impact.
 

Key Findings at a Glance

Despite increased investment in care management, execution remains constrained by limited data access and delayed insight:

• Fewer than half of plans engage members within the critical 24-hour post-discharge window
• Only 14% report real-time post-acute care data exchange across skilled nursing facilities and long-term care settings
• 81% of plan leaders say reducing hospital readmissions is the most valuable care management outcome

Why It Matters Now

As Medicare Advantage and Medicaid pressures intensify, cost and quality are no longer separable. Preventable readmissions, missed follow‑up care, and poorly managed transitions directly impact quality scores, incentive payments, and revenue stability.

This report makes the case for a strategic shift: moving beyond front‑door utilization controls toward care management enabled by real‑time clinical intelligence across acute and post‑acute settings.