US healthcare organizations face operational challenges, including rising chronic disease prevalence, workforce shortages, and growing administrative complexity. In this environment, legacy operating models are proving insufficient, prompting healthcare enterprises to reconsider their long-held hesitancy toward clinical outsourcing. As home health expenditures rise and regulatory scrutiny increases, enterprises must reimagine how they deliver efficient, high-quality, and patient-centered care. This Viewpoint explores how strategic clinical outsourcing can address key pressures by enhancing scalability, operational efficiency, and regulatory readiness. By partnering with providers offering skilled clinical talent, digital platforms, and compliance-aligned workflows, enterprises can streamline utilization management, case management, risk adjustment, and quality improvement efforts. The report also emphasizes the importance of aligning automation and AI tools with human expertise to improve outcomes while managing cost and compliance risk. Scope Geography: US Industry: healthcare Service: healthcare business process services Contents In this report, we examine: Key challenges driving the need for clinical outsourcing Functions best suited for outsourcing in clinical operations Strategic benefits of outsourcing: scalability, efficiency, and compliance Key success factors for implementation The evolving role of digital tools and AI in clinical workflows

The 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

Care management in healthcare ensures patients receive coordinated and personalized care. Traditional healthcare professionals served as care managers, coordinating care plans and facilitating communication among payers and providers. Post-COVID-19, technology advances, such as gen AI, conversational AI, and advanced automation, have transformed care management’s landscape. Advanced data analytics, telemedicine, and electronic health records have enhanced care management’s precision and accessibility. Care management platforms have improved healthcare services due to reduced healthcare costs, migration to value-based care models, and increased demand for patient-centered care. In this report, we assess 20 care management platform providers featured on the Care Management Platforms PEAK Matrix® Assessment 2024. The report will enable buyers to select the best-fit provider based on sourcing considerations and empower providers to benchmark their performance against their competition. Scope Industry: healthcare Geography: global Contents In this report, we examine 20 care management platform providers based on their: Scale of operations: revenue, buyer size, and geography Major case studies and consultative frameworks Proprietary solutions and key events Membership(s) Healthcare Payer and Provider Information Technology Sourcing and Vendor Management

Care management is a vital healthcare aspect that ensures patients and members receive coordinated and personalized care. Traditional healthcare professionals served as care managers, coordinating care plans and facilitating communication among payers and providers. Post-COVID, technology advances such as gen AI have transformed care management. Advanced data analytics, telemedicine, and Electronic Health Records (EHRs) have enhanced care management’s precision and accessibility. Care management platforms have improved healthcare services due to reduced healthcare costs, migration to value-based care models, and increased demand for patient-centered care. In this report, we assess 20 care management platform providers featured in the Care Management Platforms PEAK Matrix® Assessment 2024. The report will enable buyers to select the best-fit provider based on their sourcing considerations and empower providers to benchmark their performance against their competition. Scope Industry: healthcare Geography: global This report is based on Everest Group’s annual RFI process for the calendar year 2023, interactions with leading care management platform providers, client reference checks, and an ongoing analysis of the care management platforms market Contents In this report, we: Assess care management platforms market trends Examine enterprises’ sourcing considerations Compare providers’ key strengths and limitations Membership(s) Healthcare Payer and Provider Information Technology Sourcing and Vendor Management

The growing cost of healthcare services and a gap in the quality of care provided in traditional fee-for-service models have propelled the traction of value-based care models in the market. With this in mind, the Centers for Medicare and Medicaid Services (CMS) has planned for increased value-based care adoption by transferring all Medicare fee-for-service beneficiaries into a care relationship with accountability for quality and a reduction in the total cost of care by 2030. While alternate care delivery models, such as home-based care and virtual care, were initially brought on due to the onset of the pandemic, they are being utilized by enterprises to improve continuity of care, reduce costs, and drive value for their member/patient base. However, with a growing push toward value-based care and improving overall population health, both payer and provider perspectives require further investments for integrated care management and effective utilization management. Providers can fulfill enterprises’ clinical and care management operations requirements by delivering clinical services from cost-effective locations and deploying advanced technology solutions built on a foundation of clinical, claims, and Social Determinants of Health (SDoH) data for personalized care programs and engagement. In this report, we assess 15 healthcare providers featured on the clinical and care management operations PEAK Matrix®. The study will enable healthcare enterprises to identify suitable providers to transform their business processes and differentiate themselves. Scope Industry: healthcare business process Geography: global The assessment is based on Everest Group’s annual RFI process for the calendar year 2023, interactions with leading healthcare payer operations providers, client reference checks, and an ongoing analysis of the healthcare business process services market Contents In this report, we examine: 15 healthcare providers featured on the clinical and care management operations PEAK Matrix® Providers’ capabilities and market shares Providers’ key strengths and limitations Membership(s) Healthcare Payer and Provider Business Process Sourcing and Vendor Management

The healthcare industry faces challenges such as a shortage of clinical talent, a growing elderly population, and disparities in care access. Chronic diseases are on the rise, influenced by lifestyle choices and air quality. According to the CDC, chronic diseases chronic diseases contribute significantly to increased healthcare spending and mortality. To bridge this gap, healthcare organizations must deliver cost-effective care, expand infrastructure, and address Social Determinants of Health (SDoH) to improve access. Proactively identifying high-risk patients is essential for efficient resource allocation and cost reduction. Innovations in care delivery, targeted interventions, and investments are required to enhance care quality and outcomes. In this viewpoint, we discuss the trends driving care management policies’ adoption, outsourcing opportunities, and the evolution of care delivery. It also highlights challenges in delivering quality care and suggests ways for providers to support enterprises in overcoming these obstacles, with the ultimate goal of achieving superior patient care outcomes. Scope Industry: healthcare Geography: North America Contents In this report, we examine: Key market trends driving the increased outsourcing of care management operations A look into the past, present, and future dynamics of healthcare models Key challenges that enterprises face in handling care management operations and the solutions providers offer to support them Membership(s) Healthcare Payer and Provider Business Process Sourcing and Vendor Management

Value-based care models have gained significant traction in the market with growing costs of healthcare services and a pronounced gap in the care quality provided under traditional fee-for-service models. Consequently, the Centers for Medicare and Medicaid Services (CMS) plans to drive the adoption of value-based care by transferring all Medicare fee-for-service beneficiaries into a care relationship with accountability for quality and lower total cost of care by 2030. While the pandemic initially drove alternate care delivery models, such as home-based care and virtual care, enterprises are increasingly using them to improve the continuity of care, reduce costs, and drive value for their member/patient base. However, this push toward value-based care requires further technology investments from both payers and providers for integrated care management and effective utilization management. Providers can fulfill enterprises’ clinical and care management operations requirements by delivering clinical services from cost-effective locations and deploying advanced technology solutions built on a foundation of clinical, claims, and Social Determinants of Health (SDoH) data for personalized care programs and engagement. In this research, we assess 15 healthcare service providers featured on the Clinical and Care Management Operations PEAK Matrix®. We provide a relative positioning and analysis of the providers’ market shares and evaluate their strengths and limitations. The study will enable healthcare enterprises to identify suitable providers to transform their business processes. Scope Industry: healthcare business process Geography: global The assessment is based on Everest Group’s annual RFI process for calendar year 2023, interactions with leading healthcare clinical and care management operations providers, client reference checks, and an ongoing analysis of the healthcare BPS market Contents This report features a detailed analysis of 15 healthcare service providers and includes: Relative positioning of the providers on Everest Group’s PEAK Matrix® for Clinical and Care Management Operations Comparison of the providers’ capabilities and market shares Everest Group’s analysis of the providers’ strengths and limitations Membership(s) Healthcare Payer and Provider Business Process Sourcing and Vendor Management

COVID-19 significantly impacted care management technology adoption for healthcare payers and providers. They recognized the importance of leveraging technology to ensure continuous care while reducing transmission risk. The pandemic highlighted the value of data analytics and population health management for understanding disease trends and identifying high-risk populations. By leveraging data-driven approaches, healthcare payers and providers can allocate resources, personalize treatment plans, and address the needs of vulnerable patient groups, thereby improving patient outcomes and healthcare system resilience. Care management technology enables data collection, analysis, and visualization, empowering effective response and resource allocation during COVID-19. Technology solutions are vital for seamless collaboration among stakeholders in care coordination and communication. Patient-centered care models have also gained traction with technology enabling patient engagement and access to resources. Overall, the pandemic accelerated the adoption of care management technology, transforming healthcare delivery and emphasizing the importance of leveraging technology to meet the evolving needs of patients, providers, and payers. In this report, we assess start-ups that offer dedicated care management services, software, and solutions, focusing on their core capabilities and market impact. Scope Industry: healthcare Geography: global Contents In this report, we: Discuss payers and providers’ care management adoption levels Examine the drivers in the care management market Introduce a framework to evaluate high-potential start-ups in the care management market Highlight the trailblazers in care management, including their assessment, leaderboard, and profiles Membership(s) Healthcare Payer and Provider Information Technology Sourcing and Vendor Management

On January 6, 2021, UnitedHealth Group’s Optum acquired Tennessee-based healthcare technology company Change Healthcare for roughly US$13 billion (including about US$5 billion debt). Upon the deal’s completion in H2 2021, Change Healthcare will become a part of OptumInsight, Optum’s data and analytics arm. The acquisition promises to make Optum a partner of choice for enterprises, especially in areas where both Optum and Change Healthcare are dominant, such as payment integrity, Revenue Cycle Management (RCM), and data analytics. The acquisition is also expected to provide more mature, comprehensive, and end-to-end solutions; however, how the firms leverage their combined position in the future will be vital to serving enterprise clients. This viewpoint analyses the acquisition in detail, identifying the key drivers, the acquisition’s implications on healthcare industry stakeholders, post-acquisition considerations, and Everest Group’s views on the healthcare industry’s future course as consolidation continues in the market. Membership(s) Healthcare IT Services (ITS) Healthcare Payer and Provider Business Process Sourcing and Vendor Management

Healthcare enterprises are facing rising costs, increasing consumerism , and regulatory push toward value-based care. As a result, these enterprises are looking beyond the administrative processes of claims and network management, to reduce the cost of healthcare and provide better care. Additionally, the recent growth in care-focused collaboration models, such as Accountable Care Organizations (ACOs) and alternative payment models (reimbursements linked to value), is making the enterprises shift their focus towards care management. However, despite the increased focus on care management, clinical and care market is unstructured and lacks standardization when compared with other healthcare processes such as claims, network and RCM. This, coupled with other challenges such as talent shortage and limited technology deployment, is pushing enterprises to seek third-party help. In order to effectively tackle challenges associated with Clinical and Care Management (CCM), enterprises are looking for third-party support. In the absence of a structured and established market, enterprises find it difficult to meet their sourcing needs from one single vendor. Different categories of vendors are, hence, emerging; each with its unique value proposition. Scope Industry: CCM Operations Services Geography: Global Contents In this research, we analyze the CCM market across the following dimensions: Drivers behind high CCM demand Key sourcing considerations for CCM enterprises Key categories of vendors operating in the CCM market Membership(s) Healthcare & Life Sciences BPO