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Patients and members face significant challenges in accessing timely care. The treatment burden involves dealing with insurance, juggling appointments, figuring out transportation, keeping track of medications, and managing medical bills. Nearly 60% of insured adults encounter issues with their health coverage. On top of that, Americans spend an average of 8 hours per month coordinating their health care needs. This not only leads to frustration but also contributes to delays, inefficiencies, and gaps in care that impact health outcomes.
How can we redesign the customer experience (CX) to truly put patients and members first, ensuring they can easily access and benefit from the care they need? It starts with creating a user-centric journey that empowers consumers to make informed, confident decisions.
This is where artificial intelligence (AI)-powered CX comes into play, offering a transformative approach to reshaping the health care journey. By embracing AI and data-driven insights, health plans and providers can create a more personalized experience, ultimately leading to better outcomes for both consumers and organizations.
Designing a Member-Centric Journey
The key to better health care access and outcomes lies in shaping the entire experience around what consumers really need. Whether it’s seniors on Medicare, Medicaid recipients, or younger, tech-savvy generations, each group has its own set of challenges and expectations.
An omnichannel approach, underpinned by AI-driven solutions and empathetic human support, is key to meeting these diverse needs and enabling personalized and preemptive engagement throughout the health care journey.
Payers and providers can further optimize the health. care consumer experience by:
- Enabling proactive care and wellness: Consumers today are interested in preventive care and wellness guidance, and they increasingly expect health plans to support these services. AI-enabled solutions can help make this a reality. AI-powered chatbots, for instance, provide round-the-clock support by answering questions, guiding members through preventive care, and helping them stay on track with their treatment plans. AI-driven platforms—especially generative AI and agentic AI—help deliver multilingual, culturally relevant engagement around preventative screening, vaccinations, and medication adherence. Meanwhile, predictive analytics can identify members at risk of developing chronic conditions, enabling early intervention to prevent costly complications.A leading managed care provider of government-sponsored health care proactively engaged at-risk members, addressed concerns, and scaled agent support—resulting in a >65% conversion rate and a 10% save rate. Such a holistic approach not only enhances engagement but also creates a more inclusive and accessible health care experience for diverse populations.
- Simplifying access to care and scheduling: One of the most frustrating aspects of health care is the difficulty in finding and scheduling the right care at the right time. Missed appointments and care delays are major factors behind poor health outcomes. AI-assisted scheduling streamlines access to care with a real-time time view of appointment availability and personalized appointment recommendations based on the individual’s preferences and history. In addition to simplifying appointment booking, AI can help manage appointment cancellations and no-shows. By analyzing patient and member data, predictive analytics identify those likely to miss appointments, enabling proactive reminder campaigns and easy rescheduling. For seniors with limited access to or familiarity with technology, voice-enabled AI assistants, coupled with human support, simplify scheduling to ensure they receive the best care.A Fortune 50 health plan and a long-standing Medicare Advantage provider rolled out an omnichannel engagement strategy that combined outbound campaigns, nearshore agent support, and data-driven outreach. This approach resulted in a 2.8-fold increase in scheduled Medicare appointments and a 70% reduction in costs, improving care utilization, closing critical gaps, and safeguarding the health plan’s Centers for Medicare and Medicaid Services (CMS) rating.
- Demystifying cost and coverage: The complexity of insurance plans—whether employer-sponsored, government-funded, or individual—often leaves members confused about their coverage. AI-powered self-serve solutions simplify this by presenting coverage details, out-of-pocket costs, and billing information in a clear, understandable way. Similarly, AI-driven knowledge bases break down complex insurance terminology, helping health plan agents guide members through options that best fit their needs. Real-time cost estimation tools provide accurate predictions for procedures, medications, and treatments based on a member’s insurance coverage.This streamlining ensures better continuity of care–a key factor in reducing health care costs, emergency department visits, and hospitalizations–ultimately benefiting health plans, patients, members, and clinicians alike.
- Improving care coordination: Patients often interact with various providers—from primary care physicians (PCPs) to specialists, urgent care centers, and hospitals. Depending on their health status, insurance coverage, and personal circumstances, many may not see a PCP regularly. Even when they do, recalling and communicating critical health details such as past treatments, specialist visits, or medications can be challenging. These gaps in information lead to inefficiencies and fragmented care.AI is transforming care coordination by enabling data interoperability, breaking down long-standing silos across health care systems. By aggregating and analyzing data from disparate sources—including electronic health records (EHRs), pharmacy databases, and wearable devices—AI-driven platforms create a unified patient profile. This allows physicians to gain comprehensive insights into a patient’s medical history, risk factors, and treatment adherence, reducing redundancies and unnecessary procedures.
Overcoming Challenges and Building Trust
While AI-powered CX solutions offer immense potential to transform the health care experience, there are still challenges to overcome. Issues surrounding data privacy, security, and the accuracy of AI algorithms remain concerns for patients, health plans, and providers. To build trust, health care organizations must implement robust data protection measures and ensure that AI solutions are transparent, explainable, and aligned with patient-centric care principles.
It’s also crucial to acknowledge the role of human interaction in health care. While AI can enhance efficiency and streamline processes, it’s essential to balance it with the empathetic, personalized care that patients and members need and expect. Blending AI-driven technology with human compassion is the key to a consumer-centered experience—one that not only simplifies the journey but also leads to better outcomes for all.
This article is written by Rajesh Subramaniam and was first published in First Report Managed care