The Future of Healthcare: How Payers Are Transforming Care Delivery 

Artificial intelligence (AI) and digital innovation are reshaping nearly every industry. Traditionally, the role of payers—health insurance companies—has been limited to processing claims, managing costs, and ensuring compliance with regulations. However, with technological advancements, changing patient expectations, and the push toward value-based care, payers are emerging as active players in care delivery. 

At HIMSS25’s Emerge Innovation Experience, industry experts discussed the evolving role of payers in healthcare and how AI, virtual care, and data-driven strategies are creating new models of patient engagement. The key takeaway? For true innovation to succeed, there must be better alignment between payers and providers, ensuring that both sides work toward common goals. 

Payers as Catalysts for Change 

Health insurers now have unprecedented visibility into patient care journeys. With access to vast amounts of data spanning multiple providers and care settings, payers can analyze utilization patterns, predict health risks, and implement preventive strategies that improve patient outcomes while controlling costs. Unlike the traditional fee-for-service model, which often incentivizes volume over value, payers are increasingly embracing models that reward quality and efficiency. 

This shift is largely powered by AI and predictive analytics. By harnessing big data, insurers can proactively identify at-risk patients, provide personalized interventions, and support care teams with actionable insights. 

Aric Sharp, CEO of Value-Based Care at Clover Health, highlighted the role of AI-powered technologies in facilitating early diagnosis and improving clinical decision-making. Clover Health, like many innovative payers, is investing heavily in technology to ensure that care is not only reactive but also preventative. 

The Rise of AI in Member Services 

A major area where AI is making an immediate impact is member services. Traditionally, patients have struggled with navigating the complexities of health insurance—understanding coverage, filing claims, and getting answers to critical questions. Many find calling their insurer frustrating, often facing long wait times and confusing explanations. 

Heather Lavoie, Chief Information Officer at Horizon Blue Cross Blue Shield of New Jersey, emphasized that today’s members demand quick, seamless interactions. “People don’t want to call us,” she stated. “They want answers.” 

To address these challenges, insurers are deploying AI-driven chatbots and virtual assistants that provide instant responses to common queries. AI can summarize policy details, explain coverage options, and guide members through claims processing without human intervention. Not only does this improve the customer experience, but it also reduces administrative burdens and staffing shortages within call centers. 

Khin-Kyemon Aung, Senior Director of Healthcare Services at SCAN, pointed out that staffing call centers has become increasingly difficult. AI-powered platforms, such as Cresta, are now being used to assist human agents in real-time, providing automation and guidance during complex care conversations. This hybrid approach ensures that customer service remains both efficient and empathetic. 

Expanding the Scope of Virtual Care 

Virtual care has seen explosive growth, and payers are now leveraging telemedicine to expand access and reduce costs. By integrating telehealth into their networks, insurers can offer 24/7 access to healthcare professionals, reducing the reliance on expensive emergency room visits and in-person consultations. 

AI is accelerating this trend by enhancing remote diagnostics and treatment plans. AI-driven tools can analyze symptoms, recommend next steps, and even assist in disease management by tracking vital signs through wearable devices. 

While these advancements are making care more accessible, challenges remain. Aung acknowledged that while AI can streamline processes, it cannot address all underlying issues in healthcare delivery. Social determinants of health—such as income, education, and access to nutritious food—continue to impact patient outcomes. AI can assist in identifying these challenges, but a comprehensive strategy involving both payers and providers is necessary to tackle them effectively. 

Aligning Payers and Providers: The Biggest Hurdle 

One of the biggest barriers to innovation in healthcare is the disconnect between payers and providers. Both operate within the same ecosystem but often have conflicting incentives. Payers focus on reducing costs and managing risk, while providers prioritize patient care and maximizing reimbursements. These differing priorities can create friction and slow down the adoption of innovative models. 

Sharp pointed out that payers and providers are often “solving problems in different ways.” To truly transform healthcare, alignment is needed. When insurers and healthcare systems collaborate on shared goals—such as reducing hospital readmissions or improving chronic disease management—patients benefit from more coordinated care. 

Some payers are taking a more proactive approach by forming partnerships with healthcare providers to align incentives. Accountable Care Organizations (ACOs) and risk-sharing agreements encourage both sides to work together toward value-based outcomes rather than volume-based reimbursement. These models reward efficiency, preventive care, and patient satisfaction, ultimately leading to better health results at lower costs. 

Beyond Claims: A Holistic Approach to Member Health 

Traditionally, insurers have focused on claims data to assess risk and set premiums. But as healthcare becomes more data-driven, payers are incorporating additional sources of information to build comprehensive member profiles. 

Lavoie discussed how Horizon BCBS is leveraging sensor data, health risk assessments, and behavioral analytics to gain deeper insights into member health. This allows insurers to offer more personalized care management programs, tailoring interventions based on individual needs rather than one-size-fits-all approaches. 

For example, members with chronic conditions can receive customized health coaching, medication reminders, and digital tools to track their progress. AI-powered platforms can detect early warning signs of complications, enabling proactive interventions that prevent costly hospitalizations. 

Disrupting the Status Quo 

Sharp raised a thought-provoking point: “We have to think about breaking the way the system works in its entirety.” He even suggested that the traditional revenue cycle—how providers bill and collect payments—could become obsolete if new models emerge that eliminate administrative inefficiencies. 

The future of healthcare may involve a complete redesign of how payments, services, and patient interactions are structured. Direct-to-consumer healthcare models are already gaining traction, allowing patients to bypass insurance altogether and pay for services out-of-pocket. Subscription-based healthcare, employer-sponsored direct contracting, and AI-powered risk assessment models may further disrupt the traditional landscape. 

A Collaborative Future 

As AI, telehealth, and data-driven insights continue to reshape healthcare, payers will play an increasingly active role in care delivery. However, the key to success lies in greater collaboration between payers and providers. Without better alignment, the potential of these innovations will remain underutilized. 

The industry must move beyond its entrenched silos and embrace a unified approach that prioritizes patient-centric care. By fostering partnerships, leveraging technology, and rethinking traditional models, healthcare can transition from a reactive, cost-heavy system to a proactive, efficient, and accessible one. 

The discussions at HIMSS25’s Emerge Innovation Experience highlight that while challenges remain, the future of payer-driven healthcare is full of promise. The next decade will likely bring even more advancements, but one thing is certain: the healthcare revolution is already underway, and payers are at the center of this transformation.