麦肯锡-重塑医疗支付方：数字化与人工智能转型指南 Rewiring healthcare payers A guide to digital and AI transformation

March2025

Mcsey

&company

HealthcarePractice

Rewiringhealthcare

payers:AguidetodigitalandAItransformation

AlthoughpayershavebeencomparativelyslowtoadoptdigitalandAItoolsforsomevalidreasons,healthcarepayerdigitaltransformationcouldhelpthemcreatemeaningfulvalueandboostresilience.

byFlorianNiedermann,KarlKellner,MathisFriesdorf,andRobLevin

Healthcarepayershavereadyaccesstothe

toolstheyneedtobuilddigital-first,data-driven

organizations.Successfulhealthcarepayerdigitaltransformationscouldsubstantiallyincrease

consumerandcaregiversatisfaction,carequality,andorganizationalefficiency.Moreover,the

potentialfinancialbenefitsarevast.According

toMcKinseyanalysis,forevery$10billionofpayerrevenue,AIsolutionscouldsave$150million

to$300millioninadministrativecosts,save

$380millionto$970millioninmedicalcosts,andincreaserevenuesby$260millionto$1.24billion.

1

Yetintermsoftheirdigitalmaturity,healthcare

payerslagbehindtheglobalaverage.Theyalso

lagbehindotherinformation-intensiveindustrieswithhighvolumesofinteractionswithusers,suchasbankingandgeneralinsurance.Inbanking,

forexample,from2018to2022digitalleadersincreasedtheiruseofdigitalsaleschannelsby30percent,boostedcall-centerefficiency,andincreasedtheirTSRby8.2percent.

2

Pressureonpayerstoacceleratetheirdigital

transformationsisintensifyingbecausecost

pressuresmaybeaddressableonlywith

automation,especiallyintheUnitedStates,wheregovernmentreimbursementrateshavenotkept

pacewithrisinghealthcarecosts.

3

Thisarticle

exploreswhypayershavestruggledtorewiretheirorganizationsandwhattheycandodifferently

tomakethemostofthedistinctiveopportunitiesavailabletotheminthisageofdigitalandAI.

Barriersimpedingpayers’digitalandAImaturity

Payersfaceadistinctsetofchallengesthatwillneedtobetackledhead-ontocreate

anenvironmentthatsupportsdigitalandAItransformation.

Siloeddata.Siloeddataispervasiveatpayers

andcaredeliveryorganizationswhosesystems

arehighlyfragmented.Beyondthat,caredeliveryorganizationsmaybereluctanttosharedata

withpayersoutofconcernthatdoingsocould

affectpricingnegotiations.Severalhigh-profile

cybersecurityincidents,

4

combinedwithprivacy

regulations,

5

confoundpayers’abilitytosharedataacrossthedigitalhealthecosystem.

Stakeholderresistance.Withinpayerorganizations,corecapabilitiesfordrivingengagement,such

asdigitalmarketing—consideredthehighest

competitivepriorityinotherindustriessuchas

retailbanking—areunderdeveloped.Specifics

ofthehealthcareindustry,includingregulations,

requireadditionalknow-howtonavigate.Likewise,

manytraditionalemployeesacrossthehealthcarelandscape—expertsintheirfieldswithdecades

ofexperiencefollowingcomplexprocessesto

ensurecomplianceandsafeguardagainstrisk—

mayberesistant(orunwilling)toradicallyrethink

businessprocesseswithdigitalandAI.Forexample,theresultsofa2021surveyrevealedthatwhile

63percentofsurveyedpatientswereinterestedinadoptingdigitalhealthsolutionsbeyondtelehealth,only14percentofsurveyedphysicianshadinvestedinadigitalfrontdoor.

6

Atthesametime,member

adherencetodigitalcaremanagementisaknown,persistentchallenge.Forexample,onestudy

revealedthatonly10percentofuserscontinuedtoactivelyengagewithdigitalmentalhealthappsaftersevendays.

7

Payerorganizationmodels.Functionswithin

payerorganizationsarefrequentlysiloed,and

somemayhavetheirownmotivationstomaintainthestatusquoratherthanfacilitatechange.

Forexample,adoptingAItohelpreviewprior-

authorizationrequestsmightincreasecall-centervolumes.Coordinated,holisticplanningisneeded

1ShubhamSinghalandJessicaLamb,“TheAIopportunity:Howpayerscancaptureitnow,”McKinsey,June5,2024.

2“TheMcKinseyguidetooutcompetingintheageofdigitalandAI,”McKinseyonBooks,accessedMarch4,2025.

3ShubhamSinghalandJessicaLamb,“TheAIopportunity:Howpayerscancaptureitnow,”McKinsey,June5,2024.

4SteveAlder,“HealthcareDataBreachStatistics,”TheHIPAAJournal,January20,2025.

5“TheHIPAAPrivacyRule,”USDepartmentofHealthandHumanServices,updatedSeptember27,2024.

6JennyCordina,JenniferFowkes,RupalMalani,andLauraMedford-Davis,“Patientslovetelehealth—physiciansarenotsosure,”McKinsey,February22,2022.

7AmitBaumeletal.,“Objectiveuserengagementwithmentalhealthapps:Systematicsearchandpanel-basedusageanalysis,”JournalofMedicalInternetResearch,2019,Volume21,Number9.

Rewiringhealthcarepayers:AguidetodigitalandAItransformation2

Rewiringhealthcarepayers:AguidetodigitalandAItransformation3

Delivery

capabilities

toavoidconflicts,allocateresources,andalignefficiencytargets.Therearealsotailwindssuchasregulationsencouragingdatasharingand

reimbursementmodels—forinstance,value-basedcare—thatrelyonfrequentdatasharing.

Despitethesebarriers,payersdemonstrated

theirabilitytoinnovateduringthefirstyearofthe

COVID-19pandemic.Inthathistoricmoment,manydisincentivesimmediatelydissolved,givingrisetoasurgeintelehealthwelcomedbycliniciansand

patientsalike.ThenumberofvirtualvisitsinApril2020was78timeshigherthanithadbeentwo

monthsearlier,accountingfornearlyone-thirdof

outpatientvisits.8Similarradicalchangeis

neededtoacceleratethepayerindustry’s

transformationtodigitalandAI.Bytakinga

structuredapproach,payerscanbuildenoughmomentumtoovercomeundeniablehurdles

andachievesufficientbusinessresultsforthetransformationtobecomeself-sustaining.

Therewiredapproachforhealthcarepayers

Therewiredapproachtodigitaltransformationfocusesonsixareascorrespondingtocriticalenterprisecapabilities(Exhibit1).9

8JennyCordina,JenniferFowkes,RupalMalani,andLauraMedford-Davis,“Patientslovetelehealth—physiciansarenotsosure,”McKinsey,February22,2022.

9EricLamarre,KateSmaje,andRodneyZemmel,“Rewiredtooutcompete,”McKinseyQuarterly,June20,2023.

Exhibit1

SixenterprisecapabilitiesarecriticalforsuccessfuldigitalandAItransformations.

Transformationalvaluecomesfromcarefulandcoordinatedexecutionacrossallareasoffocus

Alignmentonvalue

1.Business-leddigitalroadmap

Alignseniorleadershipteamonthevision,value,androadmapforthetransformation;

reimaginebusinessdomainstodeliveroutstandingcustomerexperiencesandtolowerunitcosts.

2.Talent

Ensurethatyou

havetherightskills

andcapabilitiesto

innovateandexecute.

3.OperatingmodelIncreasethe

metabolicrateof

theorganizationbybringingbusiness,

operations,and

technologytogether.

4.TechnologyMaketechnology

easierforteamstousesotheycan

innovateatpace.

5.Data

Continuallyenrichdataandmakeiteasily

accessibleacrosstheorganizationtohelp

improvecustomer

experienceand

businessperformance.

6.Adoptionandscaling

Maximizevaluecapturebyensuringtheadoptionandenterprisescalingof

digitalsolutionsandbytightlymanagingthetransformationprogressandrisks.

Change

management

Source:EricLamarre,KateSmaje,andRodneyZemmel,“Rewiredtooutcompete,”McKinseyQuarterly,June20,2023.

McKinsey&Company

Rewiringhealthcarepayers:AguidetodigitalandAItransformation4

Business-leddigitalroadmap

Thetransformationjourneystartswithcreating

adigitalroadmap.Manycompanieshave

hundredsofprojectsrunninginparallel,withnonedeliveringbusinessresultsatscale.Weinstead

recommenddividingbusinessprocessesintoten

to15domains—suchasmarketingandsales—eachrepresentingthematicallyconnectedprocesses.Bystartingwithaclearfocusononeortwobusiness

domainsandagoalofimprovingperformanceby

morethan25percent(Exhibit2),theorganization

canfocusitsattentionandbuildmomentumfor

thebroadertransformation.Decisionsaboutwheretostartcanbeinformedbyareviewofperformanceagainsttargetsinareassuchascustomerand

caregiversatisfaction,medicaleffectiveness,employeesatisfaction,efficiency,andsales

effectiveness.

Exhibit2

Payerscanstartthetransformationinjustafewdomainstobuildmomentumanddeliverquickwins.

Illustrative

Low

LowHigh

Feasibility

Executivesponsorship

Datareadiness

Technologyreadiness

Easeofadoption

Easeofenterprisescaling

ValueCustomerexperienceFinancialbenefits

SpeedtovalueSynergywithotherdomains

Business

strategy

Services

ProductEnrollment

andbilling

Potentialwave1Care

management

Networkandcontracting

Riskaccuracy

Utilization

management

Potentialpilot

Marketingandsales

Corporatefunctions

ITClaims

High

McKinsey&Company

Rewiringhealthcarepayers:AguidetodigitalandAItransformation5

Startingapilotwithdomainsinwhichthe

feasibilityoftransformationsuccessis

comparativelyhigh—suchasmarketingand

salesorenrollmentandbilling—canhelppayersbuildinitialmomentumanddeliverquickwins.

Toexplaintherationaleforstartingwiththese

domains,considerbanking.Comparedwithbanks,payersaremissingtwocriticalcomponentsof

userengagement:

—Digitalmemberaccess.Inbanking,digitalis

thedominantmarketingchannel,accounting

for61percentofspendasof2023,

10

whileforpayers,digitalaccountedforjust17percentofspendasof2021.

11

Bykick-startingtheirdigitalmarketingefforts(forexample,throughsearchenginesandonlineads),payerscouldincreasethenumberofdigitaltouchpointsduringsales,creatingadistinctivememberexperience.

theyhavehigherpotentialvaluefromincreasedefficiencyandmore-targetedmedicalspend.

Talent

RewiringfordigitalandAItransformationrequires

atalentbenchwithcriticalbusinessandITskills.

Becausethehealthcareindustryoveralltendsto

lagbehindothersindigitalization,payersmaylack

theskillsneededtoreenvisionandrebuildbusinessprocessesusingdigitalandanalyticstoolsincludingAI.Talentplanningcouldemphasizeacquiringor

developingtalentintheITorganization(forexample,ITarchitects,datascientists,anddataengineers)

andfillingimportantrolesonthebusinessside.Thelatterincludesexperiencedproductowners,projectleaders,andanalyticstranslators,whoseroleisto

helpleadersidentifypromisinganalyticsusecasesandthen“translate”thebusinessrequirementstoITprofessionals.

—Omnichannelsalesandservice.Ifpayers

supportedseamlesstransitionsacross

channels(forexample,fromonlineportalsto

supportviachat),morememberswouldstart

theirengagementondigitalchannels(rather

thanpickupthephone,forexample),knowing

theywouldreceivemorecontinuousservice.

Moreover,payerscanusetheirunderstandingofmembers’channelandformatpreferences

tomakepersonalized“nextbestaction”

recommendationsthatcouldincreaseresponserates.Likewise,thedownstreamimplicationsofdigitalizingandstreamliningmember

engagementcouldbesubstantialbecause

manyback-officeinefficienciesarisefrom

insufficientdatacollectionandlowdataqualityatinitialpointsofsalesandservice.

Toachieveat-scaleimpact,payerscouldlaunch

theirfirstfullwaveinthedomainswiththehighestvalueatstake—inparticular,caremanagement

andnetworkandcontracting,whichhavebeen

historicallyunderfunded.Althoughthesedomainsaremorecomplexthanthoseinthepilotwave,

Takingadomain-drivenapproachfacilitates

talenttransformationbecauseitenablespayers

toinvestinupskillingtheworkforceinstepwise

fashionratherthanallatonce.Payersthathave

hadtoattractoutsidetalenthavebeensuccessfulinemphasizingthebenefitsofworkinginan

industrywithahighdegreeofjobsecurityand

whosemissionistoimprovehumanhealth.Inmanycases,however,fillingcriticalrolessuchasproductownersmayrequirepayerstopairhealthcare

expertswithtechnicalexpertstogettherequisitelevelofknowledge.

Operatingmodel

Organizationscanreimaginetheoperatingmodel

inlinewiththedigitalroadmap.Thiswouldentail

selectivelysettingup“agilepods”domainby

domainaspartofthetransformationjourney.Agilepodsareself-sufficient,cross-functionalteams

withend-to-endaccountabilityfordeliveringa

product,experience,orserviceusingmicroservicestopromoteagilityandindependentscaling.

12

Althoughagilepodshavebeenshowntoaccelerateinnovation,theyshouldbereservedfordomains

10RossCosner,“HowCMOscanmaximizetheirmarketingbudgets&preventcuts,”FinancialBrand,September27,2023.

11GabeIsaacson,MarinaIvanenko,andCaraRepasky,“DigitalengagementnowtypifiestheMedicareAdvantageexperience,”McKinsey,March9,2023.

12Tech:Forward,“Rethinkingconventionalwisdom:Futureofdigitaltechinfrastructure,”blogentrybyChandrasekharPandaandHenningSoller,McKinsey,June26,2024.

Rewiringhealthcarepayers:AguidetodigitalandAItransformation6

andprocessesinwhichthebusinesscasefor

acceleratedinnovationisclearandinwhichusingdigitalandAIcangiveacompetitiveedge—for

example,casemanagementbutnotpayment

processing.Industriessuchasbankingthatrolledoutagilepodsandmicroservicesacrossevery

businessdomainarebeginningtoquestiontheirnecessityinsomecases,especiallybecausetheyaddcomplexity.

13

Likewise,payerscanempowerpods,astrueend-

to-endownersofbusinessprocessandtechnology,tomake“fitforpurpose”decisionsabout

technology.Forexample,onepodmayneedgenAIexpertisetooptimizedataqualitysothatitcancollectallrequiredinformationtoprocessaclaim,whileanothermayneedneuralnetworkexpertisetowriterules-optimizationalgorithmsthatenabletraceabilityandexplainabilityintheadjudicationprocess.

Technology

Payerscouldbringordertotheirfragmented

technologyestatesbyreorganizingITsolutionsintoflexibleandindependentplatforms.

14

Toreplace

outdatedcoreadministrationsystems,resource-

constrainedpayerITorganizationscanturnto

vendorsformature,modernoff-the-shelfplatformsandusegenAItoreengineerthebusinesslogic

encodedinthemtofacilitatethetransition.

Incaseswherefullreplacementisimpracticalor

tooexpensiveinthenearterm,payerscanstill

captureplatformbenefitsbybuildinginterface

layersthatstreamlineandsimplifyinteractionswithlegacycoresystems,offeringeasy-to-usemodernAPIs.Forexample,alargeglobalhealthinsurer

establishedamodernintegrationlayerontopofitsregion-specificcoresolutions,enablingworkflowstobemanagedinauniformwayacrossgeographies

withouttheneedtoreplacethecoresystemsthemselves.

ModernizingcoreplatformscanfreeupITcapacitytofocusonstepchangeadvancesthatcangive

payersadistinctiveedge,suchasfine-tuning

adjudicationandprior-authorizationprocessesandbuildingtailoredmemberofferings.ThisworkcanbeenabledbyembeddingAImodelsandensuringrapidinnovationthroughmicroservicesowned

byagilepods.

Integrationplatformswithbuilt-inworkflowenginescanbridgethegapbetweenoff-the-shelfvendor

platformsandcustomAI-enabledmicroservices,

enablingbusinessestoflexiblyreshapetheir

workflowswithminimalITsupportthroughno-codeandlow-codeofferings.Embeddingstrong

datapipelines(forexample,machinelearning

operations15)intointegrationplatformscanhelp

ensureaseamlessflowofdatabetweensolutionsandanalyticalmodels.

Data

Inmostpayerorganizations,dataishoused

indozensofsilosmaintainedbynumerousbusinessunitsandoftenstoredondifferenttechnologies.

Hereagain,payerscanborrowapagefrom

otherindustriestodevelop“dataproducts”toimproveinternaldatasharing.

16

Thesehigh-

quality,ready-to-usedatasetscanbereusedacrosstheorganizationtohelpbreakdown

organizationalsilosandfacilitatescalingofthedigitaltransformation.

Beyondsharingdatainternally,payersthataspiretobecomeorchestratorsofhealthcareecosystemsandguidepatientsthroughthesystemalongcarepathwayswillneedtobuildoutinteroperabledataecosystemsacrosshealthcarestakeholders.

13Tech:Forward,“Rethinkingconventionalwisdom:Futureofdigitaltechinfrastructure,”blogentrybyChandrasekharPandaandHenningSoller,McKinsey,June26,2024.

14OliverBossertandDriekDesmet,“Theplatformplay:Howtooperatelikeatechcompany,”McKinsey,February28,2019.

15EricLamarre,KateSmaje,andRodneyZemmel,“MLOpssoAIcanscale,”McKinsey,March27,2024.

16VeeralDesai,TimFountaine,andKayvaunRowshankish,“Howtounlockthefullvalueofdata?Manageitlikeaproduct,”McKinsey,June14,2022.

Rewiringhealthcarepayers:AguidetodigitalandAItransformation7

Payersthatarewaitingforregulatorstoresolve

thedatainteroperabilitychallengewithformal

guidelineswillbeunlikelytoreapthebenefitsof

datasharingatscale.Instead,payerscouldusethetransitiontovalue-basedcaretocreateawin–win

valuepropositionfordatasharingwithcaredeliveryorganizations.

17

Oncepayersandcaredeliveryorganizationshavealignedtargetstooptimizepatientcareusingdata-drivenapproaches,digitaltwinscanbejointlybuiltupandusedtooptimizeprocessesatpointsofcareincludingtraditionalsettings,telehealthofferings,anddigitalsolutions.

Adoptionandscaling

Ensuringsuccessfuladoptionandscalingisa

prerequisiteforvaluegeneration.Forpayers,thiscomesdowntothefollowingprinciples:

—Adopta‘crawl,walk,run’approach.Startwith

oneortwodomainswithcomparativelylowback-endcomplexity,suchasenrollmentandbilling,todemonstratethatmovingfromcurrentmaturity

ofdigitalofferings(asevidencedbyconsistentlylowuserratingsofpayerapps,forexample)to

outstandingdigitalproductscancreatevalue.

—Focusonadoptionofsolutionsasmuchas

building.Implementingdigitalproductswith

immediatevaluetostakeholderscanboost

adoptionandscalingwithouttheneedfor

extensivechangemanagementandtraining.

Forexample,employeeshavelongstruggled

withnavigatingfragmenteddataandareusuallyquicktoembrace360-degreeviewsofmemberandcaseinformation.

—Createtherightperformanceinfrastructure.Emphasizetrackingofsupportingmetrics(for

example,automationrate)asmuchastarget

metrics(suchasadministrativecostreductionandimprovementinmedicaloutcomes).Includedigitalandanalyticstalenttracking(suchas

forrecruitmentandupskilling)inperformanceinfrastructureasarequiredenabler.

—Adoptenterprisepoliciesandprocesses

fordigital.Payerstraditionallyhavestrong

organizationalsiloswithcorporatefunctionssuchasHR,legal,procurement,andfinancethatareunaccustomedtoagilewaysofworking.Movingfromthesesilostoend-to-endprocess-orientedcollaborationmodelssupports

cross-functionalpodsandacceleratesthepaceofinnovation.

—Upskillacrossalllevelsoftheorganization.

Becausetheirbusinessisrelativelystable,

payerstypicallyhavelittleexperiencewith

radicalinnovation.Changemanagementthusbecomesevenmoreimportant.Thisentails