Interoperability pays for itself. Here’s the math.

When a new regulation lands, most organizations ask the same question first: what is the minimum we need to do to comply?

It is a rational question. Interoperability requirements arrive unfunded, with deadlines, on top of everything a payer, provider, or health system is already carrying, whether they land as CMS-0057-F in the US, the European Health Data Space, or a national exchange program. Doing just enough is the path of least resistance. It is also, on the numbers, the most expensive option on the table.

Denise St. Clair has heard that reasoning many times. When I asked her about it, she quoted it back to me almost word for word before answering it.

“It’s a box we have to check. I’ll just do the bare minimum. It’s unfunded. What am I going to get in return? A lot. You’re going to get a lot.”

Denise is worth listening to for an unusual reason: she has been on every side of this. As a patient, she spent eight years undiagnosed while her data sat in disconnected systems, and finally had treatment approved through electronic prior authorization in an hour instead of weeks. As a policymaker, she helped write the first US rule requiring FHIR and worked on what became the first version of CMS-0057-F, which now requires payers to handle prior authorization electronically.

Today she is Vice President of Health Policy and Interoperability at Global Alliant, where she leads their work on putting FHIR standards into production, though she speaks here as the patient and the policymaker, not for her employer.

When she makes the investment case, she is arguing for the system that saved her life, from inside the industry that runs it. That is worth ten vendor whitepapers, mine included.

So here is her case, and mine, for why the bare minimum is the most expensive option on the table.

The real cost is the workflow you keep

The compliance mindset frames the technology investment as the cost. That gets the accounting backwards. The cost is what you are paying right now to stay manual:

• staff hours spent chasing charts
• faxing forms
• sitting on hold
• and re-entering data that already exists somewhere else in the system.

Those hours are so deeply baked into operations that they no longer show up as a line item. They just show up as headcount, backlog, and burnout.

Prior authorization is the clearest place to see it, because it is the sharpest version of a general problem: an administrative step sitting between a clinical decision and the treatment, where information has to move before the patient can. The name changes by country. Referral approvals, funding requests, treatment authorizations, cross-border record requests. Almost every health system runs some version of these, and almost every one still runs part of them on paper, portals, and phone calls.

It is also the workflow where both sides pay for the manual version. The provider pays in staff hours, hold music, and resubmitted forms. The payer pays in review time, and then again in the downstream cost of a patient who deteriorated while waiting in the queue.

One of the simplest wins comes before a request is even submitted. When systems are connected electronically, a provider can establish in moments whether a treatment needs prior authorization at all, instead of building paperwork for a request that was never required. In Denise’s words, you save thousands of hours of going through charts and submitting paperwork. The catch is that it only works when provider and payer are actually connected that way, and many still are not.

What the numbers say

The US measures administrative waste in healthcare more closely than most systems do, partly because it has more of it to measure. That makes its figures useful even where the rules are different.

The CAQH Index, the standard industry measure of administrative transaction costs, puts a manual prior authorization at roughly $11 for a provider, against about $6 when it is handled electronically, a figure that already accounts for staff time, hold time, documentation, and appeals. What it does not count is the delay itself.

Denise has seen what that looks like at program scale.

In the electronic prior authorization pilots and process tests she has been part of, she describes a return on investment of over 200%. Not from an exotic use case. From the basics: checking whether authorization is needed, submitting the request with the clinical evidence attached, and getting the decision back through the same electronic channel. That figure comes from her own pilots rather than an industry average, but it points in the same direction the transaction costs do.

Yes, there is an upfront investment. The technology has to be set up and the data has to be organized so systems can actually use it. Denise is direct about that. But once that foundation exists, it does not just serve one workflow. The same connected data serves care management, quality measurement, and every future exchange requirement, which is why organizations that go early keep finding new returns on the same investment.

The returns that compound

The efficiency case alone justifies the investment. What makes it compound is everything downstream of it. Clinicians get to practice medicine. The doctors Denise works with describe having complete information in their workflow as empowering, because it lets them be effective and do the job they studied and worked so hard to do. She puts herself in their position to make the point.

“It is amazingly rewarding to be able to use your education to do what you were meant to do, and make that best decision with the best possible information, because you have it all in one place.”

Patients notice, and patient satisfaction is not a soft metric. Someone who is diagnosed faster, treated sooner, and kept informed rates their care differently from someone who spent weeks in an approval queue, and in value-based arrangements those ratings feed directly into how organizations are paid.

That holds true for star ratings and quality bonuses in the US, and for the outcome-linked contracts and quality frameworks spreading through European systems. The organization that delivers the faster, better-informed experience is paid more for it, not just thanked for it.

And healthier patients cost less. Denise makes this point with her own price tag: keeping her stable on a treatment costing more than $50,000 a month is still cheaper than the alternative version of her, deteriorating through emergency admissions and hospital stays. Faster, better-informed decisions do not just feel better. They bend the cost curve on the most expensive patients in your population.

The widening gap

In the US, the deadlines attached to CMS-0057-F make some of this investment mandatory anyway. The rule obligates payers to handle prior authorization electronically, and it lands on every provider that transacts with them. The strategic question is not whether to comply. It is whether to treat the mandate as a floor or a ceiling.

Organizations that treat it as a ceiling will spend real money to become minimally compliant and capture almost none of the return. Organizations that treat it as a floor build the connected data foundation once and collect on it everywhere.

The regulation differs by country. The math does not. The European Health Data Space sets its own requirements for cross-border access to health data, the Netherlands has legislated electronic exchange, and Germany is rolling out a national patient record. Take the CMS rule out of the story entirely and the argument still stands, because the efficiency gains, the clinician experience, and the cost of keeping patients sick while paperwork moves are not features of US regulation. They are features of manual work.

Denise’s story started with eight years lost to disconnected data and ended with a system that worked in one hour. Between those two points sits a set of investment decisions, made by organizations like yours.

“If you go all in and put the investment up front, the return is priceless.”

Hear it from her

Denise makes this case in 2 minutes better than I have in a thousand words, so I will hand over to her: watch her message to payers, providers, and health systems weighing this investment. Or watch our full conversation about what happens when interoperability fails.