Despite a decade of digital transformation investment, member and patient experience in health care remains fragmented, reactive, and costly. Siloed data, authorization bottlenecks, unclear billing. These aren't isolated pain points—they're structural challenges that erode trust, inflate cost-to-serve, and put Star Ratings at risk.
The new Everest Group report, supported by EXL, outlines a pragmatic path forward built on unified data, redesigned workflows, and AI that delivers measurable ROI.
The problem with fragmented data
Fragmented data isn't just an operational inconvenience. It's a compounding financial liability. When clinical, administrative, and engagement systems don't communicate, the consequences multiply: redundant interactions, billing disputes, payer-provider friction, and escalating costs. The result is higher cost-to-serve, revenue volatility, and declining member and patient trust.
Incremental upgrades can't fix a structurally misaligned model. Sustainable transformation demands a different approach.
Key takeaways from the report
Experience gaps have direct financial consequences. Poor member and patient experience drives churn, lowers Star Ratings, increases grievance rates, and inflates administrative costs. Even marginal declines in performance can translate into significant revenue impact.
Fragmented data is the root cause—not the symptom. Siloed architectures prevent unified, episode-level visibility. Without addressing underlying data and workflow misalignment, additional technology investments risk amplifying inefficiencies rather than resolving them.
AI delivers results only when built on the right foundation. The report's FASTER framework—Foundation, Alignment, Streamline, Transform, Embed governance, Reinforce—provides a staged roadmap that prioritizes structural readiness before scaling AI. This sequencing is what converts AI investment into measurable outcomes.
The right partner accelerates transformation and reduces execution risk. Most healthcare enterprises can't execute this shift alone. The report outlines what to look for in a strategic partner: integrated data capabilities, process redesign expertise, scalable AI operating models, and embedded performance governance.
How EXL helps
EXL helps healthcare payers and providers translate strategy into measurable outcomes by:
- Building governed, interoperable data architectures for real-time, enterprise-wide visibility
- Redesigning member and patient journeys with outcome-driven precision
- Deploying scalable AI-enabled operating models that improve resolution accuracy and reduce cost-to-serve
- Embedding real-time analytics and outcome-based KPIs for continuous improvement
Get the Everest Group report
Orchestrating the Next Era of Member and Patient Experience in Healthcare delivers a clear analysis of today's structural challenges and a practical framework for solving them.