Showing 122 results
-
State of the Market
Next-gen Patient and Member Experience: A Healthcare CX State of the Market
June 30, 2025In today’s dynamic healthcare landscape, Patient and Member Engagement (PME) has become a strategic imperative for healthcare enterprises and service and platform providers. Historically overlooked and limited to administrative touchpoints, PME has evolved into a mission-critical function that impacts patient/member satisfaction and business outcomes, such as retention, medication adherence, care outcomes, and cost improvements. Rising expectations, omnichannel demand, regulatory pressures, and advanced technology have accelerated the transition toward seamless, intelligent, and personalized engagement across the care journey. In this report, we analyze the PME’s evolving role in healthcare and its significance in driving better outcomes. The report assesses key adoption trends, identifies technology and organizational accelerators, and highlights the barriers that limit PME’s scaling across the industry. Focusing on real-world enterprise priorities, the report outlines how healthcare organizations are using gen AI, predictive analytics, and agentic AI to enable self-service, deliver personalized communication, and proactively retain members and patients. Additionally, the report examines the emergence of Systems of Execution (SoE) and their potential to unify data, drive AI-led engagement, and convert insights into real-time execution across touchpoints. It also provides sourcing guidance and strategic recommendations for payers and providers, emphasizing the need for a PME lead to drive enterprise alignment and measure experience success.
-
June 12, 2025As healthcare continues its transition to value-based, patient and member-centric care models, CIOs are increasingly under pressure to deliver seamless, proactive, and personalized experiences across the care continuum. Traditional Customer Relationship Management (CRM) platforms digitize communications but fall short in orchestrating real-time, intelligent engagement. The result is often fragmented experiences, high patient churn, inefficient workflows, and unmet member expectations. To address these limitations, healthcare enterprises are turning to Systems of Execution (SoE) – intelligent platform layers that go beyond passive data repositories to drive real-time decisioning and workflow automation across clinical and administrative functions. SoE represent the next evolution of CRM, which makes it capable of orchestrating adaptive, AI-driven engagement journeys that respond dynamically to clinical risk signals, social determinants of health, and benefit changes. In this Viewpoint, we explore SoE’s transformative potential across healthcare CRM by highlighting real-world use cases that improve care coordination, automate workflows, and elevate patient and member engagement.. Scope Industry: healthcare Geography: global Contents In this report, we explore: SoE’s role in transforming patient and member engagement across healthcare organizations A detailed roadmap for healthcare CIOs to implement SoE effectively, including foundational enablers such as unified data fabrics, AI-powered decision engines, and adaptive workflows A three-stage SoE maturity model with illustrative use cases and implementation best practices for each stage Strategic guidance to align CRM modernization with value-based care goals to improve engagement, care coordination, and operational efficiency
-
June 04, 2025Healthcare enterprises are increasingly recognizing the strategic value of Data, Analytics, and AI (DAAI) as data-driven decision-making becomes central to achieving business and clinical outcomes. While DAAI initiatives have traditionally focused on cost containment and operational efficiencies, there is now a clear shift toward enhancing patient experiences and driving improved health outcomes. This evolving focus is prompting organizations to invest in robust data integration capabilities and advanced analytics, with particular emphasis on data privacy, value-based care, and population health management. Although payers have historically led DAAI adoption, providers are rapidly advancing their capabilities. They are essential in shaping enterprise DAAI strategies and roadmaps, modernizing infrastructure, and delivering actionable insights that support high-impact decision-making. As a result, healthcare organizations are realizing measurable improvements in performance, care delivery, and patient engagement. In this report, we assess 32 healthcare DAAI providers featured on the Healthcare Data, Analytics, and AI Services PEAK Matrix® Assessment 2025. The report analyzes the healthcare DAAI services market size, DAAI service themes for healthcare enterprises, and providers’ capabilities and market success. The research will enable enterprises to select the best-fit provider for their sourcing needs. Scope Industry: healthcare Service: healthcare DAAI services Geography: global Contents In this report, we assess: Healthcare DAAI services market trends Each provider’s capabilities and market success Providers’ key strengths and limitations
-
April 22, 2025As US healthcare providers grapple with a turbulent economic and regulatory landscape, new tariffs and evolving policies are reshaping operational and financial realities across the sector. In response, providers are reassessing spending, delaying technology investments, and seeking more cost-effective operations. This report explores how Revenue Cycle Management (RCM) providers can strategically help healthcare organizations navigate this disruption. It highlights key actions such as adopting flexible pricing, enhancing operational agility, and deploying targeted AI to improve efficiency and safeguard revenue. Designed for RCM leaders and healthcare stakeholders, the report offers practical guidance on turning disruption into opportunity by aligning solutions with shifting provider needs. Scope Industry: healthcare Geography: North America Contents This report covers the impact of tariffs and regulations on healthcare providers and outlines strategic and portfolio-specific actions RCM providers can take to mitigate risk, enhance value, and drive growth. Memberships Healthcare Payer and Provider Business Process Revenue Cycle Management Sourcing and Vendor Management
-
April 03, 2025The payment integrity market is strategically shifting from post-payment recovery to proactive pre-payment accuracy, thereby reducing costs and enhancing efficiency. AI-driven tools are advancing fraud detection, real-time claims validation, and predictive risk modeling, while next-generation technologies, such as blockchain, are being explored for transparency. The industry is also seeing stronger collaborations among solution providers, healthcare organizations, and regulators to build integrated ecosystems. Additionally, cloud-based platforms are gaining traction and reinforcing the drive toward automation, efficiency, and improved payment accuracy in an evolving healthcare landscape. Scope Industry: healthcare Geography: global Contents This report analyzes 24 payment integrity solutions providers and includes their: Relative positioning on Everest Group’s PEAK Matrix® for payment integrity solutions Capabilities and market shares Key strengths and limitations
-
March 06, 2025The Utilization Management (UM) healthcare market faces challenges such as administrative burdens in prior authorization and inconsistent clinical criteria, causing delays and inefficiencies. To overcome these issues, payers are partnering with specialized UM service providers, integrating generative AI, automation, and clinical expertise to streamline workflows and enhance decision-making. Payers are increasingly adopting outcome-based pricing models, linking payments to patient health outcomes rather than service volume. These collaborations improve operational efficiency, accelerate care delivery, reduce costs, and ensure high-quality, evidence-based patient care, ultimately boosting provider alignment and patient satisfaction. In this report, we analyze 18 providers featured on the Utilization Management Operations PEAK Matrix®. The report positions providers relative to each other and evaluates their strengths and limitations. The study will enable healthcare payers to identify suitable providers to transform their business processes and differentiate themselves from competitors. Scope Industry: healthcare Geography: US This assessment is based on Everest Group’s annual RFI process for the calendar year 2024, interactions with leading UM operations providers, client reference checks, and an ongoing analysis of the UM operations market Contents In this report, we examine: The Utilization Management Operations PEAK Matrix® Assessment 2025 The UM operations provider landscape Providers’ key strengths and limitations Membership(s) Healthcare Payer and Provider Business Process Sourcing and Vendor Management
-
Tech Vendor Spotlight
Healthcare’s Digital Backbone: A Deep Dive into Data Management Platforms
Feb. 26, 2025Healthcare organizations generate massive data volumes from EHRs, IoT, labs, and billing systems, making effective data management essential. Interoperability, governance, and real-time analytics challenges hinder seamless data flow and insight generation. Healthcare data platforms address these issues by offering AI-driven analytics, ETL pipelines, and EHR connectivity, transforming raw data into actionable insights. These platforms improve operational efficiency, enhance patient outcomes, and enable data-driven decision-making. However, balancing innovation with compliance remains vital as organizations navigate regulatory complexities and privacy concerns. Advanced solutions ensure secure, scalable, and intelligent data management, enabling predictive analytics and real-time interoperability. As the healthcare landscape evolves, data platforms will be pivotal in optimizing workflows, streamlining care coordination, and driving digital transformation across the industry. In this report, we analyze the data platforms landscape, including key solution components, considerations to select the right tool, and leading providers. It highlights healthcare data platforms’ evolution from traditional data storage to AI-driven analytics, real-time interoperability, and predictive insights. The report profiles 15 leading technology providers that offer data platforms, highlighting their capabilities and industry use cases. Scope Industry: healthcare Domain: healthcare data platforms Geography: global Contents In this report, we provide: Each provider’s company overview Provider’s capability, market trends, and innovation dimensions Case studies demonstrating capabilities in the healthcare data management space Membership(s) Healthcare Payer and Provider Information Technology Sourcing and Vendor Management
-
Feb. 12, 2025The healthcare payer market is poised for significant shifts in 2025, driven by growing Medicare Advantage enrollments, rising medical loss ratios, and evolving regulatory frameworks. Payers are facing increasing financial and operational pressures, requiring a strategic focus on cost efficiency, value-based care, and technology adoption. As healthcare expenditures rise and enrollment dynamics shift, service providers have a vital role in supporting payers with technology-enabled solutions. This report analyzes key market trends, buyer priorities, and outsourcing opportunities in 2025. It examines the evolving payer landscape, key digital solutions, and capabilities expected to be in demand across payer functions, including claims management, care management, risk adjustment, and payment integrity. By offering strategic insights and actionable recommendations, this report equips service providers with the recommendations needed to help payers navigate the complex healthcare ecosystem and capitalize on emerging growth opportunities. Scope Industry: healthcare Geography: US Services: payer Contents In this report, we focus on: Key trends shaping the healthcare payer market in 2025 Key buyer priorities from Everest Group interactions and surveys in the healthcare payer market The market’s future outlook Memberships Healthcare Payer and Provider Business Process Sourcing and Vendor Management
-
Jan. 27, 2025Generative AI can potentially revolutionize the healthcare payer industry, driving innovation across critical areas like claims processing, member engagement, and care management. By enhancing operational efficiency and improving outcomes for both payers and members, it is becoming a key enabler for transformation. However, adoption is not without its challenges, including concerns about data privacy, model accuracy, ethical considerations, and the resource demands of training AI models. Providers are addressing these hurdles through technologies such as encryption, anonymization, federated learning, and scalable cloud infrastructures, ensuring secure and seamless integration into existing workflows. As generative AI becomes a key driver of industry innovation, providers are gradually transitioning from experimental pilot projects to large-scale implementations. In this report, we analyze the value promise of generative AI across the healthcare payer value chain, highlighting the problems it addresses and the adoption of generative AI in the healthcare payer market. We also examine 13 leading providers, highlighting their capabilities, partnerships, and generative AI roadmap. Scope Industry: Healthcare payer Geography: North America The assessment is based on Everest Group’s annual RFI process for the calendar year 2024, interactions with leading healthcare payer service providers, client references, and Everest Group’s ongoing analysis of the payer market Contents In this report, we examine: The value promise of generative AI across different segments of the healthcare payer value chain Generative AI market adoption in healthcare payer Service provider capabilities Membership(s) Healthcare Payer and Provider Business Process Sourcing and Vendor Management
-
Provider Compendium
Healthcare Payer Business Process as a Service (BPaaS) Solutions – Provider Compendium 2024
Dec. 16, 2024The healthcare payer outsourcing market is rapidly evolving as payers strive to enhance efficiency, control costs, meet member expectations, and navigate complex regulations. With a growing focus on member-centricity and streamlined core administrative processes, Business Process as a Service (BPaaS) has emerged as a key strategic solution. Payers now demand modular, contextualized, and scalable solutions tailored to specific business lines, such as Medicare or Medicaid. In response, providers are innovating with Line-of-Business (LoB)-specific solutions, robust platform partnerships, and comprehensive consulting capabilities to support payers on their BPaaS transformation journeys. In this report, we provide comprehensive, fact-based snapshots of 14 healthcare payer BPaaS solution providers. The report examines the providers’ revenue scale, client base, deployment models, revenue split by offerings, value chain coverage, plan sizes, plan types, key clients, and proprietary solutions and tools. This research enables healthcare payers to identify suitable providers to transform their business processes and achieve differentiation. Scope Industry: healthcare Geography: US Contents In this report, we examine 14 healthcare payer BPaaS solutions providers based on their: Scale of operations including revenue, client base, deployment model, revenue split by offerings, value chain, plan size, and plan type Key clients and proprietary solutions and tools offered Membership(s) Healthcare Payer and Provider Business Process Sourcing and Vendor Management
