Great expectations from Payers (and everyone) to build a patient-centric HealthTech ecosystem

Why this matters: The broken state of Interoperability

Today, most patients navigate a healthcare maze burdened by portal logins, paper forms, and redundant data entry. Care remains fragmented, and critical information often arrives late—if at all. This lack of data liquidity costs the U.S. health system an estimated $265 billion annually in waste and inefficiency. 

Historically, Payers and Providers acted as custodians of patient data, limiting how and when patients could access it. That paradigm is shifting. Under the CMS Interoperability Framework, patients-not institutions-become the primary stewards of their health data. They can choose any app, commercial or non-commercial, to retrieve their information from any network node, without additional logins or portal credentials.

This shift mirrors broader consumer trends. In banking and retail, customers already enjoy on-demand access and digital identity-driven authentication. Healthcare is finally catching up.

“For decades, bureaucrats and entrenched interests buried health data and blocked patients from taking control of their health. That ends today.” – Robert F. Kennedy Jr., HHS Secretary

What’s new: CMS Interoperability Framework

The CMS Interoperability Framework sets voluntary criteria for creating CMS-Aligned Networks that enable real-time, secure, standards-based data exchange across patients, Providers, Payers, and apps.

5 Pillars for a Patient-Centric Health Ecosystem

The framework is anchored on five pillars:

1. Patient Access & Empowerment: To ensure individuals can retrieve their health data effortlessly using apps of their choice without extra logins.
2. Provider Access & Delegation: To allow clinicians and their delegates to access the complete treatment data securely.
3. Data Availability & Standards Compliance: To mandate adherence to FHIR R4, US Core, and USCDI v3 standards.
4. Network Connectivity & Transparency: To focus on publishing endpoints and performance metrics, creating a connected, accountable ecosystem.
5. Identity, Security & Trust: To reinforce authentication, consent management, and HITRUST-level security compliance.

The early movers: Who signed on & who hasn’t

At the White House event, over 60 companies pledged to advance this vision by Q1 2026.

Notable absences: As on the date of this publication some major players, including Payers like Cigna, Kaiser Permanente, or EHR vendors like Veradigm (Allscripts), Meditech, large health systems like HCA Healthcare, Universal Health are missing from the early adopter list. However, it’s not too late to join. Organizations can volunteer by implementing FHIR APIs, adopting digital identity standards, and registering in CMS-Aligned Networks.

What this means for Payers

Payers control the richest longitudinal datasets—claims, Prior Authorizations, and coverage history—critical for improving care coordination, reducing administrative burden, and enabling value-based care. However, the locus of control is shifting. Patients will dictate how their data moves, leveraging apps and tools of their choice. Payers failing to adapt risk losing consumer trust, facing regulatory enforcement, and missing competitive advantages. Conversely, early adopters can shape standards, strengthen digital leadership, and create lasting member loyalty.

What Payers must do: Mandates vs voluntary moves

As the U.S. healthcare landscape accelerates toward Interoperability, Payers find themselves at the center of this transformation. CMS has outlined clear regulatory requirements to ensure standardized, secure data sharing and patient empowerment. However, beyond these mandates lies a critical opportunity: voluntary initiatives that can differentiate early adopters, strengthen member trust, and create competitive advantage.

Mandated actions (CMS-0057-F & 9115-F)

• Implement FHIR-based APIs:
  • Patient Access API (claims, clinical data, Prior Auth).
  • Provider Access API (for treatment).
  • Payer-to-Payer API (patient opt-in required).
• Support USCDI v3, SMART on FHIR, Bulk Data IG.
• Apply security standards: HITRUST, OAuth2, audit logging.
• Deadline: By 2027, full compliance is expected.

Voluntary (but strategic) actions

• Join CMS-Aligned Networks
• Enable QR codes and Smart Health Cards for instant patient data access.
• Support digital identity (IAL2/AAL2) for frictionless authentication.
• Develop AI-driven tools integrated with Interoperability APIs for experience differentiation.

Timelines & milestones

The CMS Interoperability Roadmap represents more than compliance—it is a strategic blueprint for transforming the U.S. healthcare system into a patient-driven, data-fluid ecosystem. For Payers, these milestones signal the urgency to align technology investments, governance, and partnerships with CMS expectations. Acting early is not just about meeting deadlines; it’s about shaping the competitive landscape, reducing long-term compliance costs, and delivering superior member experiences.