Reimbursement Is Changing. Alignment Will Decide What Works

The future of healthcare reimbursement is being driven less by any single policy and more by mounting pressures across the system. Costs keep rising, administrative complexity remains high, and patients bear the brunt when incentives pull payers and providers in opposite directions. What once seemed like a gradual shift is now resembling a full-scale structural transformation. 

During a Modern Healthcare panel in late 2025, leaders from payer, provider, and policy organizations described a system strained by misalignment, yet rich with opportunity. Dr. Jerilyn Morrissey, Chief Medical Officer at CorroHealth, explained that payers and providers have negotiated themselves into opposing positions, leaving the patient in the middle of the conflict. That friction now carries a financial cost the industry can no longer absorb. 

Healthcare spending makes up roughly twenty percent of the nation’s GDP, yet only a small fraction reaches the bedside—and most of that comes after conditions have already escalated. The system still rewards reaction over prevention, and today’s reimbursement models are being called on to correct that imbalance. 

Why Value-Based Care Started Gaining Traction 

Value-based care emerged as a response to these pressures, and its goal is straightforward in theory. Care should be rewarded for keeping patients healthier, rather than for the volume of services delivered after they become sick. 

In practice, the transition has been uneven. Some organizations have demonstrated progress through accountable care organizations and hospital-at-home programs. Others remain caught between fee-for-service economics and value-based expectations. Karen Hanlon, Executive Vice President and Chief Operating Officer at Highmark Health, described the challenge of operating across both models at once. Hospitals must maintain financial stability today, while investing in care delivery approaches that pay off over time. 

Despite these constraints, value-based care has shown where alignment is possible. Hospital-at-home programs have delivered higher patient satisfaction, faster recovery, and fewer readmissions. Integrated payer-provider organizations have begun aligning incentives across pharmacy, care management, and clinical pathways. These examples suggest that the model works best when economic incentives support collaboration, rather than competition. 

Where WISeR Fits Into the Prior Authorization Debate 

Few topics generate stronger reactions than prior authorization. For clinicians, it often represents delay and administrative burden. For payers, it remains a mechanism to manage unnecessary utilization. The WISeR model attempts to narrow that divide. 

Dr. Morrissey acknowledged the frustration clinicians feel, while emphasizing the importance of context. In 2023, Medicare Advantage plans issued roughly fifty million prior authorization determinations, with a denial rate of six percent and average turnaround times approaching two weeks. During the same period, CMS issued approximately four hundred thousand determinations, with denial rates closer to twenty-eight percent and turnaround times measured in days. 

WISeR is distinct in both scope and purpose. It focuses on a targeted set of outpatient services where data shows the highest risk of waste or misuse. At the same time, it excludes inpatient care and leaves emergency and urgent care untouched. Its quality metrics and guardrails are consistent with those already familiar from value-based care programs. 

This distinction matters. Prior authorization can serve a purpose when applied selectively and supported by evidence. When used broadly, it erodes trust and diverts attention from patient care. WISeR reflects an attempt to strike a narrower balance, even as debate continues about its long-term impact. 

Why Alignment Matters More Than the Model Itself 

Behind debates about WISeR, value-based care, and other payment models lies a more basic challenge. Reimbursement struggles when payer and provider incentives drift apart.  

Dr. Morrissey framed the issue clearly, pointing to disease, not the organization on the other side of the table, as the real adversary. That perspective moves the conversation away from control and toward shared responsibility, allowing both sides to stay focused on outcomes rather than process. 

Hanlon described how Highmark and Allegheny Health Network narrowed the number of performance indicators guiding their value-based programs. Reducing variation helped clinicians focus their efforts and made collaboration more feasible. Complexity can carry its own significant cost. When organizations juggle hundreds of metrics tied to different contracts, improvement slows and accountability blurs. 

Where Technology Helps and Judgment Still Matters 

Technology came up repeatedly during the panel, often accompanied by a note of caution. Artificial intelligence and automation hold real promise for reducing administrative burdens, but poorly executed, they can amplify existing challenges. 

Dr. Morrissey outlined healthcare’s journey from data to information, knowledge, and ultimately wisdom. While automation can speed up routine tasks, clinical judgment must remain at the heart of decisions that impact patient care. 

Constructive examples are already emerging. Ambient clinical documentation tools are reducing burnout and electronic prior authorization workflows integrated into electronic health records are shortening turnaround times. At Highmark, more than half of electronic authorizations now receive near real-time responses, with clinicians reviewing denials rather than being buried under paperwork. 

What Other Payment Models Are Testing Right Now 

WISeR is not the only experiment underway. The Transforming Episodes Accountability Model, known as TEAM, introduces mandatory participation for selected hospitals and extends accountability beyond discharge. 

Panelists raised concerns about hospitals’ ability to manage care outside their walls, particularly amid staffing shortages and financial strain. Mandatory models applied too broadly risk destabilizing organizations that lack the infrastructure to succeed under new rules. Voluntary pilots with clear evaluation criteria may offer a more sustainable path forward. 

Where Reimbursement Is Likely Headed 

The future of healthcare reimbursement will not hinge on a single model. It will depend on how effectively the industry aligns incentives around shared goals. 

Value-based care, WISeR, and episode-based models all aim to shift resources toward prevention and better patient outcomes. None will succeed without trust, transparency, and collaboration. When aligned, interdependence becomes an advantage instead of a source of friction. 

Reimbursement reform remains controversial, and for good reason. Yet the panel discussion suggested cautious optimism: innovation is advancing, data is providing clearer insights, and technology can ease administrative burdens when applied thoughtfully.  

The rules, of course, are still being written. The organizations shaping them will be those willing to align around patient outcomes and recognize that collaboration is no longer optional.