The new reality
Healthcare is undergoing a seismic shift. A single negative healthcare experience can cause frustration for many members, prompting them to switch health plans. Members now expect the same seamless, anticipatory experiences they get from Netflix or Amazon – but from their health plan.
These expectations aren’t just about convenience; they’re about confidence. And meeting them means navigating a labyrinth of regulations, provider networks, and deeply personal health journeys. The challenge? Delivering personalized, proactive service in one of the most complex industries on earth.
The shift isn't just about technology adoption. It's about recognizing that transparency and consistency earns trust, and that trust directly impacts everything from Star ratings to member retention to operational performance.
This perspective builds on themes discussed in a recent Becker’s Healthcare webinar I participated in, alongside esteemed leaders from NASCO, Blue Cross Blue Shield of Kansas, and Optum, that explored how AI orchestration is reshaping member experience.
The orchestration framework that leads to loyalty
Enter the role of AI orchestration – the ability to coordinate every touchpoint in a member’s journey into a unified experience. Instead of treating interactions as separate transactions: enrollment, claims, care coordination, and wellness programs, leading health plans are building connected journeys that feel intuitive and human.
Each touchpoint builds on the last, creating cumulative trust. Members don’t have to repeat themselves. Providers don’t have to guess. And every interaction feels like part of a larger, thoughtful conversation.
Trust through transparency and consistency
As I mentioned during the webinar, “transparency and consistency earn trust.” This isn’t just a tagline – it’s a performance strategy.
And trust is being measured against a new standard. As Mike Gerrish, Chief Marketing Experience Officer at Blue Cross Blue Shield of Kansas, explained during the webinar:
“We're competing against the last company, product, or service that [members] interacted with where they had a good experience. When you think about being fast, predictive, helpful, efficient, engaging – we're really in the content management business now.”
This shift means that every interaction – whether digital or human – must be orchestrated to meet rising expectations. Members aren’t comparing their health plan to other insurers; they’re comparing it to the best experience they’ve had anywhere.
Real results: Performance that matters
The business case for orchestrated experiences extends far beyond member satisfaction. Health plans using Pega Customer Decision Hub have demonstrated measurable improvements in the metrics that matter most:
- $217 million in incremental revenue from enhanced personalization capabilities
- 40% increase in engagement and 200% improvement in email open rates
- 27% increase in online upsell and cross-sell performance
These results directly support the performance improvements mentioned in the webinar: enhanced Star ratings, reduced friction, improved service quality, and sustainable growth through trust-building.
The victories in CMS star ratings methodology demonstrate how comprehensive solutions that address member experience, streamlined operations, data-driven decision-making, and regulatory compliance create competitive advantages in an increasingly challenging environment.
Human-led, AI-enabled care
The webinar panelists were clear: AI should enhance the human element in healthcare – not replace it.
As Tina Galloway of Optum emphasized:
“AI should make it more efficient and remove the friction, and it should help us deliver better, more competent care and improve our outcomes versus being something that takes away the human element from healthcare.”
And as Lori Logan president of NASCO reminded us: “Everybody deserves a better healthcare experience.”
Achieving this vision requires health plans to embrace their evolving role as trusted healthcare partners, while maintaining their operational excellence as payers. It’s about balancing empathy with efficiency, and personalization with scale.
Final thoughts
AI orchestration isn’t just about technology – it’s about empathy at scale. It’s how health plans can deliver the kind of care that feels personal, even when it’s powered by algorithms. And it’s how we move beyond transactions to build trust – one orchestrated experience at a time.
Learn more
- Discover how Pega for Healthcare helps organizations personalize engagement for better outcomes.
- Learn how Bupa delivers hyper-personalization
- Get to know Pega Customer Decision Hub for Healthcare