The continuation governance gap exists because three conditions are simultaneously true.
Condition 1
No structured reassessment interval for continuation
PA renewal checks eligibility — is the diagnosis present, is the drug on formulary. It does not ask whether the therapy is still producing outcomes. Between renewals, refills process automatically. Some specialty agents have no PA at all.
Condition 2
Governance signals are dispersed across systems
Claims show utilization. Labs show response. Pharmacy data shows fill patterns. No system assembles these into a structured reassessment. The intelligence exists. The assembly does not.
Condition 3
Internal teams can't build it — the duty to act
The moment an internal medical director identifies a continuation concern, fiduciary obligations compel intervention. The governance review becomes a UM action. That's why no payer has built this internally at population scale.
CMS BALANCE Model launches GLP-1 coverage for Medicaid (May 2026) and Medicare Part D (January 2027). The continuation governance gap is about to get much larger.
02 / 11
The White Space
Every existing tool was designed for something else.
Capability
Claims Analytics
PA / UM
PBM Reporting
Internal Review
Cadence
Governs continuation
—
—
—
—
✓
Produces a governance artifact
—
—
—
—
✓
Advisory-only (no duty to act)
✓
—
✓
—
✓
Measured influence metric
—
—
—
—
✓
Immutable audit trail
—
—
—
—
✓
Claims analytics sees the population. PA/UM acts on individuals. PBMs report spend. Internal review triggers the duty to act. Cadence governs continuation, produces an artifact, measures influence, and maintains an audit trail. No other column fills more than one row.
03 / 11
The Finding
58–60% of reviewed members had never been structurally reassessed.
DAR 40%
Adjust 25%
Taper 20%
Switch 15%
Cohort 1 — 25,000 commercial health plan members — 90-day governance cycle
What one of those 3,450 cases looked like
Member#4,217DrugSemaglutide 2.4mg weeklyDuration16 monthsA1c at initiation8.2%Last A1c7.1% — month 4. No labs since.Dose historyEscalated 1.7mg → 2.4mg at month 6. No documented response.
DUR12DOSE_ESCLABGAP
Review: ~4 min
Determination: Adjust
De-identified composite. Representative of the clinical picture assembled for each flagged member.
04 / 11
Three Independent Populations — 65,234 Patients
The governance gap converged across all three.
Metric
Cohort 1 — Commercial
Cohort 2 — Self-Funded
Cohort 3 — NIH All of Us
Population
25,000
9,500
30,734
Data source
Claims
Claims
EHR (national)
Therapy class
GLP-1
GLP-1, Bio, Beh, Onc
GLP-1, Bio, Beh, Onc
Flagged
6,250 (25%)
2,375 (25%)
8,930 (29.1%)
Reviewed
5,750 (92%)
2,185 (92%)
Algorithmic
RIR
60%
58%
—
DAR
40%
42%
—
Zero monitoring
—
—
22.3%
GSV
$8.6M
$5.3M
—
Flag rate converged at 25–29% across all three populations. Cohort 3 (NIH All of Us) applied CGS trigger logic computationally to independent EHR data. 22% had zero therapy-relevant monitoring during entire continuation.
05 / 11
The PA Blind Spot
Where prior authorization doesn't exist, neither does oversight.
Flag rate — no PA
34%
Flag rate — with PA
19%
79%
wider governance gap where PA does not exist
62% of Cohort 2 specialty continuation members had no prior authorization at all. Plans that negotiated broad formulary access gave their members better benefits — and created a larger blind spot.
06 / 11
Advisory Signals Work
Half of advisory-only recommendations persisted without compulsion.
50%
Governance Persistence Rate
60%
Adjust persistence
45%
Taper persistence
40%
Switch persistence
No compulsion. No override. No denial authority. The treating provider independently arrived at a similar conclusion within 90 days — because the signal was clinically sound.
07 / 11
The Standard
CGS v1.1 defines what a valid governance cycle is.
Eight sections. Seven required triggers. A published specification that any organization can inspect, any attorney can review, and any regulator can evaluate.
Cohort Definition
Minimum 2,500 members. Therapy class specified.
Trigger Architecture
7 required categories. All configured and documented.
Reviewer Qualifications
Minimum 2 external PharmD/MD. No single reviewer >40%.
Outcome Taxonomy
Continue, Adjust, Taper, Switch. No fifth category.
Measurement
RIR, DAR, GPR, GSV. Formulas published.
Audit Trail
Immutable. Sealed at cycle close. No post-seal modification.
Configuration Fingerprint
Versioned and locked before cycle start.
Governance Certificate
Credential issued upon CGS-compliant cycle completion.
08 / 11
The Economics
For every $1 spent on governance, ~$19 in governance-relevant activity is documented.
Governance cost
~$6
PMPM — specialty cohort
GSV documented
$8.6M
First cycle — 25,000 members
Cost-to-signal ratio
~19:1
At $6 PMPM / 5K members
Tier
Members
PMPM
Quarterly Cost
Tier 1
<10,000
$6.00
$18/member
Tier 2
10,000–50,000
$5.00
$15/member
Tier 3
50,000+
$4.50
$13.50/member
GSV is a directional measure of governance-relevant economic activity — not a savings projection. What your organization does with the signal is a governance question, not an economic one.
09 / 11
What You Hold
The governance artifact is a new object. No existing process produces it.
Configuration fingerprint. Outcome distribution. Measured RIR and DAR. Immutable audit trail. Governance narrative. Sealed at cycle close.
Board Room
Your medical director presents a governance artifact documenting structured oversight of 25,000 continuation members. No other document in the room does that.
Stop-Loss Renewal
Your broker slides the Governance Certificate across the table. The underwriter sees documented oversight for the first time. The renewal conversation changes.
PBM Negotiation
You sit down with your PBM armed with a measured governance signal they've never seen. The conversation shifts from cost to outcomes.
10 / 11
One CSV. 90 days. One artifact.
A de-identified claims extract — the same format your analytics vendors already receive. One governance cycle. At the end, you hold a document that didn't exist before. The documented answer to "what is our continuation oversight?"
Start a pilot.
pilot@showyourwork.health
showyourwork.health
Cadence, LLC
Methodology: Cadence Governance Standard (CGS v1.1) — published at showyourwork.health
Manuscript submitted for peer review: Journal of Managed Care & Specialty Pharmacy