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  • State of the Market

    June 30, 2025
    In 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. 
  • Provider Compendium

    June 30, 2025
    The payment integrity market is shifting from post-payment recovery to a proactive focus on pre-payment accuracy, aiming to reduce costs and improve efficiencies. AI is enhancing fraud detection, real-time claims validation, and predictive risk modeling. Simultaneously, blockchain is helping boost transparency, while cloud adoption supports automation and operational agility. Collaboration among payers, providers, and regulators is also strengthening, helping develop more integrated and effective ecosystems. This report assesses 24 payment integrity providers, analyzing key aspects such as revenue scales, client bases, delivery models, value chain coverages, service segmentations, plan sizes and types, notable clients, and proprietary tools. It is designed to help healthcare payers identify the right partners to support operational transformation and gain a competitive edge in a rapidly evolving payment integrity environment.
  • Viewpoint

    June 25, 2025
    As patient expectations rise and healthcare delivery becomes more complex, access functions face increasing strain. Legacy systems and fragmented workflows can no longer handle real-time scheduling, eligibility verification, and financial clearance. Despite growing investments in AI, several organizations fail to achieve meaningful gains due to the absence of cohesive orchestration across access processes. This report introduces Systems of Execution (SoE) as healthcare enterprises’ next critical capability layer. Positioned between core systems and AI applications, SoE platforms enable coordinated, intelligent execution across patient access touchpoints. The report outlines key effective SoE tenets, including embedded AI, adaptive learning, and API-driven interoperability, and illustrates how they can transform critical touchpoints across the revenue cycle. It also profiles the evolving vendor landscape and offers strategic considerations for healthcare stakeholders seeking to optimize patient access with SoE-driven approaches.
  • Viewpoint

    June 02, 2025
    The pharmaceutical industry is significantly transforming, driven by escalating R&D costs, rising competition, and a rapidly evolving global regulatory landscape. In this dynamic environment, regulatory affairs have emerged from their traditional compliance-focused roles to become strategic business agility enablers. Enterprises are increasingly recognizing the potential of AI, generative AI, and agentic AI to reduce manual workloads, accelerate time-to-market, and improve the accuracy and consistency of regulatory submissions. This report provides comprehensive insights into AI adoption’s current state in regulatory affairs, highlighting key challenges, value drivers, and investment trends. It explores prioritized strategic and operational use cases across regulatory processes and outlines how enterprises can overcome adoption hurdles through robust governance frameworks. The report also examines specialized providers’ evolving role in this transformation. Through their domain expertise, technology capabilities, and scalable solutions, these providers help reduce risk, ensure compliance, and enable faster time-to-market. Industry Life Sciences BPS Geography Global Contents In this report, we examine: Regulatory affairs’ evolving role in life sciences Current and future AI investment trends across pharma enterprises Leading AI use cases in regulatory strategy and operations A governance framework to address AI adoption challenges The strategic role of regulatory affairs specialist providers in accelerating AI adoption Memberships Life Sciences Business Process Sourcing and Vendor Management
  • Viewpoint

    May 28, 2025
    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
  • Viewpoint

    May 08, 2025
    The shift from fee-for-service to Value-based Care (VBC) is increasing due to payer mandates and the long-term promise of improved outcomes and lower costs. However, this transformation is unfolding amid economic uncertainty, tariff-driven inflation, and healthcare provider financial strain. Several hospitals lack the capital, operational agility, or data integration required to scale VBC adoption effectively. As Centers for Medicare & Medicaid Services (CMS) expands its adoption through the Alternative Payment Model (APM) framework, healthcare providers struggle to align limited resources with long-term strategic goals. To succeed in this evolving environment, healthcare organizations must invest in automation, analytics, and AI-enabled tools that improve financial and clinical performance. Agentic AI offers the potential to ease documentation burdens, close care gaps, and support compliance in a fragmented data ecosystem. In this report, we highlight how the emerging divide in the VBC landscape, shaped by resource availability, risks exacerbating disparities in care quality and organizational resilience. The report offers actionable strategies to navigate payer demands, optimize contracts, and realign RCM provider partnerships to support value-based models. Scope Industry: healthcare Geography: North America Contents In this report, we: Simply the VBC concept Evaluate systemic barriers slowing VBC adoption Assess VBC adoption trends in the future Analyze the healthcare provider strategy blueprint for VBC’s success
  • Technology Application Deep Dive

    April 25, 2025
    As the healthcare industry prioritizes precise, efficient, and accessible care, automation is essential in addressing challenges such as inaccuracies, inefficiencies, workforce shortages, and limited access to care. Robotic technologies help bridge these gaps and enhance healthcare delivery. Healthcare robots are transforming the industry by improving medical care’s precision, efficiency, and accessibility. They come in various forms and serve multiple applications, from surgery to rehabilitation. Integrating these robots into healthcare aims to enhance patient outcomes, minimize human error, and optimize care delivery. Additionally, hospitals use these robots to assist with logistics, streamline clinical workflows, and improve operational efficiency. By reducing the burden on healthcare staff, they contribute to long-term cost savings through increased efficiency and fewer errors. This research focuses on an in-depth analysis of non-surgical robots, exploring their technology advances, impact, and future evolution in healthcare. Scope Industry: healthcare, pharmaceutical, medical devices, and diagnostics All geographies Contents Focus areas of the report include: Non-surgical robots’ technology landscape in healthcare Key factors driving R&D and adoption Key technology developers and adopters and the innovation landscape Non-surgical robots’ future trajectory in healthcare
  • Viewpoint

    April 22, 2025
    As 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
  • PEAK Matrix®

    April 03, 2025
    The 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
  • PEAK Matrix®

    March 06, 2025
    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