Health plans break through paralysis by framing journeys around the member, not the system

Most health plans today are stuck—and not in a subtle, fix-it-with-a-dashboard kind of way. They’re stuck in a complexity of their own making. They sunk millions, sometimes hundreds of millions, into technology upgrades, interoperability solutions, data lakes and shiny front-end portals. And yet, for the health plan member, healthcare experiences feel like standing in the TSA line at a third-tier airport: confusing, repetitive, opaque, indifferent and deeply impersonal.

Members notice. Churn is increasing. Medicare Star Ratings fell to 3.92 from 4.07 in 2024, with only seven plans attaining the coveted Five Stars in 2025 compared to 38 in 2024. Net Promoter Scores are flat lining. Even the most well-intentioned health plans are drowning in data and still can’t see the member clearly.

Here’s the kicker: The tools we need are already in the building.

Ambition isn’t lacking: It gets trapped in myriad disconnected systems that don’t talk to each other and operate with their own single source of truth. Members get several messages in one week and only one of them makes sense. High-fidelity data ironically leads to low-empathy execution.

Meanwhile, AI is brandished like a silver bullet with predictive models, chatbots and generative engines. But none of it matters if a member can’t refill a prescription or find a healthcare provider (HCP). When governance is chaotic and workflows are broken, AI can’t close gaps—it hardwires them.

So let’s ask the only question that matters: What if every tech investment, every data pipeline and every org chart decision were held to a single standard: Does this make the members’ experience simpler, smarter and more human? Under this lens, experience isn’t an outcome. It’s the engine of engagement. And most plans today are not asking this question. Most plans are trying to understand member journeys through claims analyses, voice-of-the-customer programs, digital tracking tools and segmented personas. These efforts often remain siloed, reactive and disconnected from real-time member behavior.

ME First turns outcomes into a shared, system-wide scoreboard. It’s not a theory. It’s a playbook—one that uses existing infrastructure to deliver the desired member experience and applies real-time data to adapt outreach. ME First enables personalization at scale, aligns teams around journey-level accountability and measures what works so next actions are more attuned to member needs.

Payers don’t need a fiscal windfall to do this. They need courage to act differently with what they already have because, in this new world, experience is strategy. The only metric that matters is whether members feel seen, heard, guided and confident enough to say: “I didn’t feel alone—and now I trust them to help me next time.”

This is the heart of ZS’s Member Engagement First (ME First) strategy. ME First is a forcing function meant to push health plans to stop optimizing for internal convenience and start building systems that serve the people navigating them. It rewires how a health plan sees, serves and supports members, through the eyes of one member on one unique journey.

ME First starts with understanding the member, not as a file in a claims system but as a human being managing care, life and competing demands. ME First leverages behavioral science to decode intent, emotion and inertia. It doesn’t simply assign risk scores and diagnostic codes— it demands organizing around omnichannel signals and unifying touch points across mobile devices, portals, in-person visits and apps into a single, intelligent picture. This isn’t multichannel chaos. This is journey-aware communication that respects member history and context. It reimagines journeys as proactive and personalized, with journey orchestration engines that guide members through life events, not business processes. No more disjointed nudges from multiple teams. Just one clear path forward, continuously adjusted based on member behavior. And it calibrates impact using closed-loop ROI measurement, tracking not just what was sent but also what worked, for whom and why.

What does it take to deliver for one member’s one unique journey in a system built for everyone and no one at the same time? The ME First strategy comes to life through seven bold shifts, each one designed to dismantle friction and connect dots so members feel like the system understands them.

The real issue isn’t data scarcity but experience absurdity. Health plans are drowning in data. Eligibility files, claims, histories, care gaps, prior authorization workflows, behavioral flags, social drivers of health overlays, real-time notifications and service calls analyzed through natural language processing. Yet members continue to receive several calls for one hospital discharge, denial letters without a single explanation and portals that feel more like a trap than a tool.

These aren’t minor misfires. Recurring events like these signal systemic dissonance. The intent is there, and the investment is real, but outcomes haven’t yet reflected the effort. Members are left to fill in the gaps.

Why does this happen? Because all that beautiful, structured and enriched data lives inside operational fiefdoms answering questions for one functional leader while ignoring the contextual relevance of the member interactions with the plan. The clinical team has one view, while member services has another. Pharmacy runs its own playbook. And the digital team? It’s A/B testing landing pages that don’t align with the rest of the member journey. Meanwhile, data continues to duplicate as the cost to store and manage it quietly grows—diverting resources from member experience, outreach and operational improvement.

Sophisticated analytics fuel questionable decisions, not because the tools are wrong but because the data isn’t unified or operationalized through a member lens. Until that happens, departments will continue to act on partial truths. A health plan cannot deliver a coherent, frictionless member experience when the infrastructure looks like a plate of spaghetti. Bolting on one more customer relationship management (CRM) system, one more chatbot or one more engagement hub isn’t the answer. The real fix? One backbone, a unified infrastructure layer that synchronizes data and generates insight and action across every team, channel and context.

Delivering a coherent journey requires a backbone, a single infrastructure layer that connects dots in real time. While inherited technology doesn’t need a complete overhaul, health plans do need to stop duct-taping solutions together and calling it “integration.”

Key elements of the backbone include:

• Real-time data fabric: A living nervous system listens across every operational stack—from claims and CRM systems to utilization management, behavioral health, pharmacy benefit managers and quality engines. It shares insights before a decision is made, not after the damage is done.
• One member, one ID: Health plans need to eliminate crosswalk tables with key matching logic buried in human brains. “One ID to rule them all” should be the new doctrine.
• Experience-led architecture: Prioritize moments that matter in the member journey—diagnoses, discharge, first denial and coverage changes. This approach respects member needs, not departmental organization structures.
• Composable services: Design modular components such as next best action engines, benefit navigation, behavioral nudges and engagement orchestration so they plug into any channel or workflow. Make them reusable across apps, call scripts and care teams.

This is not tech for tech’s sake. It’s infrastructure that enables meaningful connection at scale.

Risk scores alone won’t guide meaningful engagement. They were developed to flag costs and utilization, not mitigate member confusion or misunderstanding. While risk scores identify members who might need something in the future, they do not tell when, why or how to intervene. ME First shifts the focus from “scoring” members to detecting meaningful patterns in real time—and using those signals to guide timely, relevant action.

Imagine a member opens five denial-related emails in three days but never calls. This is more likely a confused member than a noncompliant one. A person with diabetes probably skips a prescription refill the week after a hurricane for reasons of survival, not nonadherence. When a caregiver leaves the portal midway through trying to access care information, is the issue low engagement—or poor design?

ME First systems pick up on these signals and act accordingly. These areas are ripe for AI—not to replace people but to scale emotional intelligence and prompt health plan associates to take actions they may not otherwise consider.

ME First:

• Prioritizes the right moments: Not every gap in care needs a phone call. But when signals align—such as missed refills, unread messages or declining portal logins—the plan can act before the member churns or requires more costly interventions.
• Sequences outreach: Instead of scattered check-ins from different teams, members get one well-timed nudge with the right next step—because all functions share engagement calendars.
• Personalizes with precision: Choose the right tone, channel and language based on history, literacy and past responses. It’s not just “Hey Jasmine, did you know...?” It’s “Hey Jasmine, here’s what changed for you recently, and this is what you should do next. Call us anytime to talk through your options with one of our care managers.”

Here’s what it comes down to: Don’t just push content and check a box. Push your systems to listen, learn and adapt in real time. This is how engagement rises above noise and to build trust.

Health plans don’t lack capability. The technology and data many of them have in place are ready to serve a ME First strategy. What health plans need is cohesion and reassembled systems that connect data and teams around the member experience. While a full-system rip-and-replace may look good on a CIO’s roadmap, it rarely delivers the agility ME First demands. Fixing the metaphorical wiring will get the desired results without needing to rebuild the house. Here are components that can help achieve this future:

• An API layer for experience integration: APIs act as adaptors between existing platforms and modern interfaces that members touch, exposing what matters and hiding what doesn’t so members and associates aren’t overwhelmed with raw data while missing key insights. They also translate across languages health plan operational teams and systems wouldn’t otherwise share.
• Journey orchestration layers: An intelligence engine tracks where members are in their journey and makes decisions about what to do next. Engagement across teams, channels and contexts is coordinated.
• Cloud-native AI services: Cloud-based tools plug in quickly, scale and enable smart engagement without requiring long validation cycles or extended deployment timelines.
• Cross-functional squads: Real transformation requires multidisciplinary teams that combine clinical, operational, technical and member engagement professionals, each aligned to one goal. Make member journeys seamless and measurable.

A slick member portal, an AI-powered chatbot or a data lake full of models means very little if no one is responsible for the member experience those tools create. This isn’t branding, where experience is detached from ownership. ME First demands cross-functional accountability with the authority to act. That means:

• Making friction visible: Use signal data to publish weekly friction reports that show which journeys are breaking, where members are dropping off and what those breakages are costing in dollars and reputation.
  
  Use case: A cross-functional Cardiac Recovery council focused on post-discharge interactions combines utilization management, pharmacy, digital and member services outreach into one timely discharge message with a clear follow-up regimen. The council meets biweekly to review reports that flag where members dropped off and to identify real-time solutions.
  
• Establishing governance councils: Empower cross-functional teams to resolve conflicts, eliminate redundant outreach and prioritize the fixes that matter most to members.
  
  Use case: The same cardiac recovery council implements cross-disciplinary solutions without blame, sharing lessons learned and turning the process into a repeatable operating model.
• Measuring what matters: Replace vanity metrics with experience-based ones like member effort score, time to resolution and digital abandonment.
  
  Use case: Diabetes journey dashboards track effort, timing and drop-off rather than counting sent messages or app clicks.
• Linking compensation to member outcomes: Teams won't prioritize trust, retention or resolution unless they're rewarded for them.
  
  Use case: Care management and digital teams earn bonuses based on trust score, journey completion and member retention, not reach rates or app volume measured in silos.

True accountability should be—and should feel—directional, without implied punitive actions for plan leaders or associates. It helps every team understand what good looks like, with “good” defined by the member—not the business unit.

The playbook for ME First is ready, and it doesn’t require a moon shot. The real question is whether the plans will execute.

Imagine this: Jasmine, 43, has just been diagnosed with type 2 diabetes. Overwhelmed and unsure where to begin, she expects a maze of disconnected outreach. Instead, her health plan sends a single supportive message within 48 hours: “We’re here to help you take the first steps—at no cost to you.” A link leads to a personalized page with three clear actions: Confirm her pharmacy, schedule an eye screening and connect with a health coach. Each action triggers timely, relevant follow-ups without any clutter or duplication.

If Jasmine doesn’t respond for a few days, the system doesn’t flood her inbox. One thoughtful nudge offers help from her coach. Later, when she calls about continuous glucose monitoring coverage, the agent already knows where she is in her journey. No repeating, no reexplaining.

Behind the scenes, a real-time data fabric connects Jasmine’s activity across systems—claims, pharmacy, care teams and CRM—allowing the plan to respond based on her needs, preferences and behavior. An orchestration engine sequences outreach across channels, while engagement signals are tracked to continually improve the experience.

The result is a diabetes journey that feels intuitive, respectful and human. Not built for the system but built for Jasmine. That’s ME First, in action.

This is what good looks like—an experience free from anxiety and repetitive nudges. No bots pretending to care. Just clear, coordinated and human-centered execution.

Member engagement isn’t a downstream output. It’s an upstream standard every system, investment and action must now support.

ME First begins with a shift in accountability—from internal alignment to member clarity. From tech sprawl to intelligent sequencing. From fragmented insights to unified journeys that measure ease for the member, not effort by the health plan. Me First helps health plans become the kind of organization members want to engage with because the experience feels coordinated, personal and worth their time.

The good news? You don’t need to start from scratch. Most of what you need is already in place. The opportunity now is to realign those assets, using the spine of smart infrastructure, the brain of behavioral science and the lens of the individual member. What’s needed is conviction: the will to make experience the system of record to let the journey—not inherited silos—decide what gets prioritized, measured and solved.