Future Evolutions in Health Care Policy and Pathway Development

Key Takeaways

• Utilization management (UM) policies, despite any negative perceptions that may be associated with them, are designed to improve patient access and reduce health care spending.
• UM processes such as prior authorization (PA) are based on pathways and evidence-based guidelines, influencing operational workflows and value-based care.
• The recent US election raises questions about the future of health care and possible evolutions in policy and regulation, with significant system-wide changes likely to take years to implement.

A panel of speakers consisting of F. Randy Vogenberg, PhD, Adam Colborn, JD, and Alex Sommer at the Clinical Pathways Congress (CPC) 2026 discussed potential evolutions in health care policy and regulation and how they may impact pathway developments.

The Interplay Between Pathway Development and Health Policy

The session began with an overview of how pathways are influenced by health policies, law and regulation, and care access and coverage, all of which impact patient care.

Pathways set guidelines, which in turn establish clinical boundaries. While pathways focus on patient preferences and treatment individualization, guidelines are based on real-world evidence which can help build PA policy foundation. In addition, pathways can be used to determine operational workflows, including treatment prescribing, electronic health records, and UM.

The Function and Evolution of PA

Speakers emphasized that while the general public may sometimes hold a negative view of PA, it is important to analyze these processes at a population level: PA policies are used to increase access and spread health spending across as many people as possible.

The utilization of bundled PA policies within health plans is designed to decrease the number of requirements for medications.

UM policies help manage costs, and the speakers note that government-sponsored health care systems heavily rely on such policies.

Artificial intelligence (AI) has the potential to streamline UM policies and improve their efficiency, but its foundational processes will remain the same. According to the panelists, it can be used to automate approvals and identify incorrectly submitted data, but clinical reviews should be left for the clinicians.

Upcoming Changes in Legislation

According to the speakers, the changes in leadership resulting from the recent US midterm election may significantly impact health systems, pathways, and workflows.

While the panelists expect upcoming federal hearings to focus on broad policy discussions, they see concrete action happening at the state level. The lack of friction between bill introduction and passing may contribute to new health care legislation.

Implications for Oncology Care

While the panel hypothesized system evolutions and explored the interworking frameworks of health policy and legislation, the future of health care in the US remains unknown. Major changes, especially system-wide ones that extend beyond clinical pathways, are unlikely to occur within the next 12 months, but shareholders should watch out for significant policy and regulatory updates over the next couple of years.

Reference

Colborn A, Sommer A, Vogenberg FR. Policy pathways: navigating regulation, reimbursement, and accountability. Presented at: Clinical Pathways Congress; November 10-11, 2026; Boston, MA.