The payer’s AI playbook: Redefining value in a new era of healthcare

Executive Summary

The healthcare industry is evolving toward a consumer-first model that leverages technology to reduce costs and improve health outcomes.

• The industry is shifting from a paradox of high costs and low-quality care to focus on seamless, personalized digital experiences.
• Generative AI and LLMs are key, moving beyond simple data analysis to provide deep, personalized consumer insights and new modalities for engagement.
• The ultimate goal is “agentic AI,” intelligent systems that autonomously manage complex, multi-step tasks to address labor shortages and meet demand, such as coordinating care or ensuring medication adherence.
• Payers must transform their business model by making the consumer central, using AI to integrate claims, clinical, and wearable data for deeper customer relationships, better retention, and improved risk stratification.

The healthcare industry has long been trapped in a paradox: it is an ecosystem plagued by rising costs that often delivers low-quality, low-engagement experiences. For members, this trap is a source of frustration, financial burden, and ultimately, suboptimal health outcomes. The data backs this up: a KFF report found that nearly half of U.S. adults struggle to afford healthcare costs, leading many to skip or postpone needed care. Disengaged patients are more likely to have poor health outcomes and incur higher costs, perpetuating a cycle of inefficiency and dissatisfaction. (Source: KFF)

But a new era is emerging, defined by the profound impact of technology and a fundamental shift in how we approach care. The opportunity before us is clear: to break this historical trap and deliver best-in-class, consumer-first experiences at a drastically lower cost.

The digital foundation for a new era

This shift is underpinned by two key developments. First, the rapid and massive acceleration in the adoption of digital consumer-first experiences. The consumerization of healthcare is here, and organizations must build a strong digital foundation to meet this demand. The expectation for seamless, convenient, and personalized digital interactions—similar to those found in retail or banking—is no longer a “nice-to-have” but a core requirement for engagement and trust. That is the ground floor. 

The second—and most transformative—development is the advent of generative AI and large language models (LLMs). These tools have fundamentally changed what is possible in digital healthcare. While legacy machine learning models offered us ways to segment and personalize experiences, generative AI gives us far more flexibility and power to truly understand a member as a unique individual. It allows us to move beyond simple data points to gain deep insights into consumer needs and then engage with them in entirely new ways and through different modalities. As Deloitte notes, these models possess unprecedented capabilities in natural language generation, summarization, and personalization, which are key to delivering a more human-centered experience at scale. (Source: Deloitte)

The potential of Agentic AI

The conversation around AI in healthcare often focuses on automation, but the true promise lies in what we call “agentic AI.” Agentic AI refers to intelligent systems that can work autonomously to complete sophisticated, multi-step tasks, often in collaboration with other agents and humans. 

In an industry facing labor shortages, agentic AI has the potential to add an entirely new layer of care and support. Instead of simply trying to do more with less, we can use these agents to break away from historical constraints and meet the growing demand for healthcare services. According to a McKinsey report on the topic, AI agents can manage complex administrative workflows, proactively engage with patients, help them prepare for appointments, coordinate follow-up care, and ensure medication adherence. This ability to deliver personalized care at scale, adapting to an individual’s unique journey, is now enabled in a way it was not historically. (Source: McKinsey)

Beyond NPS: Redefining the payer business

The traditional healthcare payer business model is under immense pressure. Rising costs, uncertain funding sources, and declining trust are chipping away at an already-unstable foundation. Looking ten years into the future, it is clear that this model must adapt, change, and transform. And that transformation must start by placing the consumer at the center of the business.

This means moving beyond traditional measures of success, like simple Net Promoter Score (NPS), to a more holistic view of consumer value. We have to drastically affect the way we deliver care, and that must be done through new technologies, new channels of outreach, and entirely distributed models of care. As a recent article from ZS notes, the future of health plans will be built on a smarter, more connected model powered by AI, interoperability, and real-time data to proactively reduce costs and retain members. (Source: ZS)

The benefit of this transformation is that payers can build deeper customer relationships, improve customer retention, and achieve better risk stratification and scoring. By combining data from various sources—including claims, clinical records, and wearable devices—payers can gain a comprehensive view of each member’s health journey. This allows for a proactive approach to care, enabling them to better manage the financial health of their business. Ultimately, paying for care is a combination of behavior change and a financial instrument. AI provides the ability to bring these two elements together, creating a more sustainable and valuable business model.

Our commitment to a new era of care

Over the last decade, League has served as a trusted partner in transforming the healthcare consumer experience for some of the industry’s most recognizable and forward-thinking healthcare organizations. We have an intimate understanding of the industry’s challenges and have built a strong foundation of data and insights. Today, we’re leveraging that unique expertise into a pioneering role that will help organizations navigate the AI transformation. This is bigger than simply adopting and implementing new software and technology; we’re helping them build an entirely new business model that delivers better outcomes, drives deeper consumer relationships, creates long-term financial health—and most importantly—transforms the payer’s role in the lives of their members.